Provider Demographics
NPI:1407944077
Name:KRUEGER, OTTO WALDEMAR (DC, ATC, LMT)
Entity Type:Individual
Prefix:DR
First Name:OTTO
Middle Name:WALDEMAR
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:DC, ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2785 N ANKENY BLVD.
Mailing Address - Street 2:STE. 16
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023
Mailing Address - Country:US
Mailing Address - Phone:515-964-5000
Mailing Address - Fax:
Practice Address - Street 1:2785 N ANKENY BLVD
Practice Address - Street 2:STE. 16
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4769
Practice Address - Country:US
Practice Address - Phone:515-964-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06749111N00000X
IA003632255A2300X
IA02340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAV10894Medicare UPIN