Provider Demographics
NPI:1528024197
Name:KRUEGER, JUSTIN K (MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:K
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 COLEMANS CROSSING BOULEVARD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-0000
Mailing Address - Country:US
Mailing Address - Phone:937-644-1441
Mailing Address - Fax:937-642-7760
Practice Address - Street 1:140 COLEMANS CROSSING BOULEVARD
Practice Address - Street 2:SUITE 210
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-0000
Practice Address - Country:US
Practice Address - Phone:937-644-1441
Practice Address - Fax:937-642-7760
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2017-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35082295207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2545044Medicaid
OH2545044Medicaid
OH4158394Medicare PIN