Provider Demographics
NPI: | 1558329920 |
---|---|
Name: | KRENEK, THOMAS F IV (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | THOMAS |
Middle Name: | F |
Last Name: | KRENEK |
Suffix: | IV |
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: | PO BOX 692 |
Mailing Address - Street 2: | |
Mailing Address - City: | BAYSIDE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 95524-0692 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 707-269-9550 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 2200 HARRISON AVE |
Practice Address - Street 2: | |
Practice Address - City: | EUREKA |
Practice Address - State: | CA |
Practice Address - Zip Code: | 95501-3215 |
Practice Address - Country: | US |
Practice Address - Phone: | 707-269-9550 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-05-03 |
Last Update Date: | 2013-03-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | G43797 | 2084N0400X, 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00G437970 | Medicaid | |
130004937 | Other | RAILROAD MEDICARE | |
00G437970 | Medicare ID - Type Unspecified | ||
130004937 | Other | RAILROAD MEDICARE |