Basic Information
| Provider Information | |||||||||
| NPI: | 1346240413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRESS | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 W MAIN ST | ||||||||
| Address2: | STE A | ||||||||
| City: | BUCKHANNON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 262012292 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048424444 | ||||||||
| FaxNumber: | 3048424491 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 263301651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3048424444 | ||||||||
| FaxNumber: | 3048424491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 08/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 958-OD | WV | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 001720797 | 01 | WV | BCBS | OTHER | 410042363 | 01 | WV | RAILROAD | OTHER | P00440067 | 01 | WV | RAILROAD | OTHER | 0150098000 | 05 | WV | MEDICAID | P00247169 | 01 | WV | RAILROAD | OTHER | 1346240413 | 01 | WV | NPI | OTHER |