Provider Demographics
NPI:1003838293
Name:KRAGT, ANNA K (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:K
Last Name:KRAGT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:206 W. WARREN ST
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:IN
Practice Address - Zip Code:46540-0459
Practice Address - Country:US
Practice Address - Phone:574-825-2146
Practice Address - Fax:574-524-7435
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01045002A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200101330Medicaid
IN236040026OtherMEDICARE PTAN
IN200101330Medicaid
IN223520IMedicare ID - Type Unspecified