Provider Demographics
NPI:1497784862
Name:KRUEGER, RICHARD C JR (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:C
Last Name:KRUEGER
Suffix:JR
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 GENEVA ST
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-2122
Mailing Address - Country:US
Mailing Address - Phone:505-506-1090
Mailing Address - Fax:888-734-8467
Practice Address - Street 1:2836 W 98TH PL
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-2613
Practice Address - Country:US
Practice Address - Phone:505-506-1090
Practice Address - Fax:888-734-8467
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-06982080N0001X
IL036.0848302080N0001X
WAMD 601323582080N0001X
IN01069425A2080N0001X
OK288592080N0001X
MO20120036672080N0001X
MS219872080N0001X
CAG850142080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201046030Medicaid
CA75929856Medicaid
IN000000745199OtherANTHEM PROVIDER NUMBER
INM400061466Medicare PIN
CA75929856Medicaid