Provider Demographics
NPI:1366480634
Name:KRUK, PETER G (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:KRUK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23540
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-3540
Mailing Address - Country:US
Mailing Address - Phone:858-565-0950
Mailing Address - Fax:858-565-2863
Practice Address - Street 1:8745 AERO DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1761
Practice Address - Country:US
Practice Address - Phone:858-565-0950
Practice Address - Fax:858-244-1100
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA960702085B0100X, 2085U0001X, 2085N0700X, 2085N0904X, 2085P0229X
MA2250962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
No2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083812Medicaid
CAZZZ75341ZMedicaid
CAGR0083811Medicaid
CAGR0083817Medicaid
CAGR0083813Medicaid
CAGR0083815Medicaid
CAGR0083816Medicaid
CAGR0083810Medicaid
CAGR0083814Medicaid
CATD009BMedicare PIN
CAHW529AMedicare PIN
CAGR0083813Medicaid
CAGR0083816Medicaid
CAGR0083812Medicaid
CAGR0083811Medicaid
CAI59180Medicare UPIN
CAGR0083814Medicaid
CAGR0083810Medicaid
CAHW529BMedicare PIN