Provider Demographics
NPI:1649243189
Name:KRUEGER, ROSS T (MD)
Entity Type:Individual
Prefix:DR
First Name:ROSS
Middle Name:T
Last Name:KRUEGER
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 1:1801 BARRS ST
Mailing Address - Street 2:SUITE 605
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32204-4732
Mailing Address - Country:US
Mailing Address - Phone:904-387-4424
Mailing Address - Fax:904-387-4423
Practice Address - Street 1:1801 BARRS ST
Practice Address - Street 2:SUITE 605
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4732
Practice Address - Country:US
Practice Address - Phone:904-387-4424
Practice Address - Fax:904-387-4423
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21320174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD53105Medicare UPIN
FL16948Medicare ID - Type UnspecifiedPROVIDER NUMBER