Provider Demographics
NPI:1790829992
Name:KROEKER, ROY O (DPM)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:O
Last Name:KROEKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7081 N MARKS AVE 104
Mailing Address - Street 2:PMB 358
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-0232
Mailing Address - Country:US
Mailing Address - Phone:559-432-5565
Mailing Address - Fax:
Practice Address - Street 1:7081 N MARKS AVE 104
Practice Address - Street 2:PMB 358
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-0232
Practice Address - Country:US
Practice Address - Phone:559-432-5565
Practice Address - Fax:559-432-5255
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE14010213E00000X, 213ES0103X
CAFZ216Z213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E14010Medicaid
CA196282200OtherDEPARTMENT OF LABOR
CAE14010OtherCALIFORNIA LICENSE
CA000E14010Medicaid
CA756480258Medicare PIN
CA196282200OtherDEPARTMENT OF LABOR
CA000E14010Medicare PIN