Provider Demographics
NPI:1073544375
Name:KRUK, STEPHEN M (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:KRUK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 HOSPITAL AVE 215
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1464
Mailing Address - Country:US
Mailing Address - Phone:814-371-1717
Mailing Address - Fax:
Practice Address - Street 1:145 HOSPITAL AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1462
Practice Address - Country:US
Practice Address - Phone:814-371-1717
Practice Address - Fax:814-375-4422
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-005395-L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001065654Medicaid
PAC29368Medicare UPIN
PA001065654Medicaid