Provider Demographics
NPI:1487650339
Name:KRUSE, ROGER JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:JOHN
Last Name:KRUSE
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 1:2865 N REYNOLDS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-2068
Mailing Address - Country:US
Mailing Address - Phone:419-578-7036
Mailing Address - Fax:419-537-5597
Practice Address - Street 1:2865 N REYNOLDS RD
Practice Address - Street 2:STE 130
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2068
Practice Address - Country:US
Practice Address - Phone:419-578-7036
Practice Address - Fax:419-537-5597
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35043625207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2048386Medicaid
OHKR0473103OtherMEDICARE
OH080190310OtherRRMC
OHKR7245271Medicare ID - Type UnspecifiedMEDICARE
OHKR0473103OtherMEDICARE