Provider Demographics
NPI:1750331666
Name:KROENCKE, SCARLETT MARION (DPM)
Entity Type:Individual
Prefix:
First Name:SCARLETT
Middle Name:MARION
Last Name:KROENCKE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1712 PICASSO AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-0546
Mailing Address - Country:US
Mailing Address - Phone:530-753-6280
Mailing Address - Fax:530-753-6281
Practice Address - Street 1:1712 PICASSO AVE
Practice Address - Street 2:SUITE C
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618-0546
Practice Address - Country:US
Practice Address - Phone:530-753-6280
Practice Address - Fax:530-753-6281
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3832213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00119813OtherRAIL ROAD MEDICARE
CA000E38320Medicaid
CAP00119813OtherRAIL ROAD MEDICARE
CA000E38320Medicare PIN
CA000E38320Medicaid