Provider Demographics
NPI:1518595826
Name:KRUCKENBERG, KATHERINE MARY (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:MARY
Last Name:KRUCKENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W ARBOR DR # MC081
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-1911
Mailing Address - Country:US
Mailing Address - Phone:951-282-5884
Mailing Address - Fax:
Practice Address - Street 1:9500 GILMAN DR # 851
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093-9619
Practice Address - Country:US
Practice Address - Phone:951-282-5884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1843172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program