Provider Demographics
NPI:1679524623
Name:KRUK, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:KRUK
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 1:740 REENA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-3145
Mailing Address - Country:US
Mailing Address - Phone:920-563-0888
Mailing Address - Fax:920-568-3516
Practice Address - Street 1:740 REENA AVE
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-3145
Practice Address - Country:US
Practice Address - Phone:920-563-0888
Practice Address - Fax:920-568-3516
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31765-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31765OtherUNITED HEALTHCARE
WI1000337OtherPHYSICIANS PLUS
WIK400131248Medicare PIN
WI001454375Medicare PIN
WI1000337OtherPHYSICIANS PLUS
WI080179062Medicare PIN
WI31765OtherUNITED HEALTHCARE