Provider Demographics
NPI:1285682435
Name:KRUK, KELLY M (DO, DA)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:KRUK
Suffix:
Gender:F
Credentials:DO, DA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 FERN LN
Mailing Address - Street 2:
Mailing Address - City:SAINT SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-2700
Mailing Address - Country:US
Mailing Address - Phone:304-716-1912
Mailing Address - Fax:
Practice Address - Street 1:10 FERN LN
Practice Address - Street 2:
Practice Address - City:SAINT SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-2700
Practice Address - Country:US
Practice Address - Phone:304-716-1912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDA00245171100000X
NY271534207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No171100000XOther Service ProvidersAcupuncturist