Provider Demographics
NPI:1447275623
Name:KRUEGER, KYLE R (DO)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:R
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15810 S HARLAN RD
Mailing Address - Street 2:STE. A
Mailing Address - City:LATHROP
Mailing Address - State:CA
Mailing Address - Zip Code:95330-8719
Mailing Address - Country:US
Mailing Address - Phone:209-983-9000
Mailing Address - Fax:209-983-9001
Practice Address - Street 1:15810 S HARLAN RD
Practice Address - Street 2:STE. A
Practice Address - City:LATHROP
Practice Address - State:CA
Practice Address - Zip Code:95330-8719
Practice Address - Country:US
Practice Address - Phone:209-983-9000
Practice Address - Fax:209-983-9001
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6303207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A6303Medicaid
CA020A63031Medicare ID - Type Unspecified
CA20A6303Medicaid