Provider Demographics
NPI:1194009720
Name:KROEGER, RON DAVID (B S)
Entity Type:Individual
Prefix:MR
First Name:RON
Middle Name:DAVID
Last Name:KROEGER
Suffix:
Gender:M
Credentials:B S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 MABEL C. FRY BLVD.
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099
Mailing Address - Country:US
Mailing Address - Phone:405-361-0086
Mailing Address - Fax:
Practice Address - Street 1:5131 N CLASSEN BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73118-5258
Practice Address - Country:US
Practice Address - Phone:405-767-1126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-30
Last Update Date:2011-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU081857432Medicaid