Provider Demographics
NPI:1336321769
Name:KRUEGER, ROLFE H (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROLFE
Middle Name:H
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:76 PHEASANT LN
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14227-3712
Mailing Address - Country:US
Mailing Address - Phone:716-668-1829
Mailing Address - Fax:
Practice Address - Street 1:76 PHEASANT LN
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14227-3712
Practice Address - Country:US
Practice Address - Phone:716-668-1829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY03984156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00637614Medicaid
NY0168370001Medicare PIN