Provider Demographics
NPI:1336036193
Name:KROLL, JOHN MATTHEW
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MATTHEW
Last Name:KROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:
Other - Last Name:KROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9210 S 168TH AVENUE CIR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-1624
Mailing Address - Country:US
Mailing Address - Phone:402-290-7916
Mailing Address - Fax:
Practice Address - Street 1:9210 S 168TH AVENUE CIR
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136-1624
Practice Address - Country:US
Practice Address - Phone:402-290-7916
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-23
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities