Provider Demographics
NPI:1114234440
Name:KRAUCHUK, DANIEL ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:ROBERT
Last Name:KRAUCHUK
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 1:1101 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-1702
Mailing Address - Country:US
Mailing Address - Phone:833-753-3435
Mailing Address - Fax:725-777-1304
Practice Address - Street 1:9555 S EASTERN AVE STE 290
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89123-8009
Practice Address - Country:US
Practice Address - Phone:702-870-3722
Practice Address - Fax:725-777-1304
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016276208100000X
NV2865208100000X
CA20A11543208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGM001ZMedicare PIN