Provider Demographics
NPI:1609841964
Name:KRUTKY, THEODORE K (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:K
Last Name:KRUTKY
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:PO BOX 26125
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44319-6125
Mailing Address - Country:US
Mailing Address - Phone:888-719-9020
Mailing Address - Fax:330-493-7123
Practice Address - Street 1:802 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:CUYAHOGA FALLS
Practice Address - State:OH
Practice Address - Zip Code:44221-1049
Practice Address - Country:US
Practice Address - Phone:330-929-4221
Practice Address - Fax:330-929-7513
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039773207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH729848OtherBUCKEYE COMMUNITY HEALTH
OHQ013420OtherHOMETOWN HEALTH PLAN
OH0340867Medicaid
OH000000129127OtherANTHEM
OH791111263OtherRAILROAD MEDICARE
OH000000129127OtherANTHEM
OH4259251Medicare PIN
OH0340867Medicaid