Provider Demographics
NPI: | 1811043102 |
---|---|
Name: | KRALL, JOE (OD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JOE |
Middle Name: | |
Last Name: | KRALL |
Suffix: | |
Gender: | M |
Credentials: | OD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 1415 N SANBORN BLVD |
Mailing Address - Street 2: | |
Mailing Address - City: | MITCHELL |
Mailing Address - State: | SD |
Mailing Address - Zip Code: | 57301-1015 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 605-996-2020 |
Mailing Address - Fax: | 605-990-3937 |
Practice Address - Street 1: | 1415 N SANBORN BLVD |
Practice Address - Street 2: | |
Practice Address - City: | MITCHELL |
Practice Address - State: | SD |
Practice Address - Zip Code: | 57301-1015 |
Practice Address - Country: | US |
Practice Address - Phone: | 605-996-2020 |
Practice Address - Fax: | 605-990-3937 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-01-27 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
SD | 494 | 152WC0802X, 152WP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Not Answered | 152WC0802X | Eye and Vision Services Providers | Optometrist | Corneal and Contact Management |
Not Answered | 152WP0200X | Eye and Vision Services Providers | Optometrist | Pediatrics |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
SD | 9202632 | Medicaid | |
SD | 9202632 | Medicaid | |
SD | 2390 | Medicare ID - Type Unspecified |