Provider Demographics
NPI:1407877830
Name:KRUSNIAK, JEFFREY MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:KRUSNIAK
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 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-733-2092
Mailing Address - Fax:360-788-6042
Practice Address - Street 1:3015 SQUALICUM PKWY
Practice Address - Street 2:STE 200
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-1945
Practice Address - Country:US
Practice Address - Phone:360-733-2092
Practice Address - Fax:360-788-6042
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101013559207X00000X
WAOP60390976207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4742268Medicaid
MIJK013559OtherBCBS ID NUMBER
MI200H310170OtherBCBSM GROUP ID NUMBER
MIH71299Medicare UPIN
ON13960003Medicare ID - Type Unspecified