Provider Demographics
NPI:1306849419
Name:KRUCZEK, KENNETH EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:KRUCZEK
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3506 21ST ST
Practice Address - Street 2:SUITE 605
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1212
Practice Address - Country:US
Practice Address - Phone:806-725-4130
Practice Address - Fax:806-723-7137
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6120207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX034876502Medicaid
NM000Q2634Medicaid
TX8CT089OtherBCBS TX
TX8CT089OtherBCBS TX
TXTXB125059Medicare PIN