Provider Demographics
NPI:1700835006
Name:KRUEGER, CORY SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:SCOTT
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 1:758 E COTTONTAIL RUN
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-7072
Mailing Address - Country:US
Mailing Address - Phone:928-634-7000
Mailing Address - Fax:
Practice Address - Street 1:305 S WILLARD ST
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4127
Practice Address - Country:US
Practice Address - Phone:928-634-7000
Practice Address - Fax:928-634-5649
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36238207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC32679Medicare UPIN
AZ112693Medicare PIN