Provider Demographics
NPI:1770627069
Name:KRUEGER, GARY PATRICK (OD)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:PATRICK
Last Name:KRUEGER
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 1:3636 5TH AVE
Mailing Address - Street 2:STE.300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4230
Mailing Address - Country:US
Mailing Address - Phone:619-297-4331
Mailing Address - Fax:
Practice Address - Street 1:3636 5TH AVE
Practice Address - Street 2:STE.300
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4230
Practice Address - Country:US
Practice Address - Phone:619-297-4331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5295T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0052950Medicaid
CASD0052950Medicaid
CAW0P4950AMedicare UPIN