Provider Demographics
NPI:1003862285
Name:KRUSE, THOMAS V (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:V
Last Name:KRUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302
Mailing Address - Country:US
Mailing Address - Phone:503-370-7364
Mailing Address - Fax:503-375-3643
Practice Address - Street 1:1410 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302
Practice Address - Country:US
Practice Address - Phone:503-370-7364
Practice Address - Fax:503-375-3643
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11505207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR218644Medicaid
OR218644Medicaid
ORR0000BHKMXMedicare ID - Type Unspecified