Provider Demographics
NPI:1780719146
Name:PRUKOP, FRANK EDWIN (OD)
Entity type:Individual
Prefix:DR
First Name:FRANK
Middle Name:EDWIN
Last Name:PRUKOP
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 1:200 REIDDA DR
Mailing Address - Street 2:
Mailing Address - City:KINGSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78363-7701
Mailing Address - Country:US
Mailing Address - Phone:361-595-4421
Mailing Address - Fax:
Practice Address - Street 1:1133 GENERAL CAVAZOS BLVD
Practice Address - Street 2:
Practice Address - City:KINGSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78363-7100
Practice Address - Country:US
Practice Address - Phone:361-516-0888
Practice Address - Fax:361-516-0880
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5487T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14919OtherSPECTERA PROVIDER ID
TX25812OtherOPTICARE PROVIDER #
TX454087OtherNVA PROVIDER #
TX0054FBOtherBCBS PROVIDER #
TX5487TOtherLICENSE #
TX44212OtherDAVIS VISION PROVIDER #
TX919677OtherBLOCK VISION PROVIDER ID#
TXMPO864822OtherDEA #
TXU91010Medicare UPIN
TX00878FMedicare ID - Type UnspecifiedPROVIDER #