Provider Demographics
NPI:1356963391
Name:KLUG, KYLE (OD)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:KLUG
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 1:12660 Q ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-3332
Mailing Address - Country:US
Mailing Address - Phone:402-896-3300
Mailing Address - Fax:402-896-5931
Practice Address - Street 1:12660 Q ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-3332
Practice Address - Country:US
Practice Address - Phone:402-896-3300
Practice Address - Fax:402-896-5931
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT030.0133922-EMGY152W00000X
NE1561152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist