Provider Demographics
NPI:1447320668
Name:KREGG KOONS O.D., INC.
Entity type:Organization
Organization Name:KREGG KOONS O.D., INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KREGG
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOONS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-289-4727
Mailing Address - Street 1:5535 SCATTERFIELD RD.
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013
Mailing Address - Country:US
Mailing Address - Phone:765-642-7822
Mailing Address - Fax:765-751-2207
Practice Address - Street 1:5535 SCATTERFIELD RD.
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013
Practice Address - Country:US
Practice Address - Phone:765-642-7822
Practice Address - Fax:765-642-7608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
152W00000X
IN18002701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376600Medicaid
IN100152490BMedicaid
IN100152490BMedicaid
IN100376600Medicaid