Provider Demographics
NPI:1821004177
Name:KRIENKE, RUSSELL B (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
Last Name:KRIENKE
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:PO BOX 26726
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78755-0726
Mailing Address - Country:US
Mailing Address - Phone:512-407-8686
Mailing Address - Fax:512-421-4489
Practice Address - Street 1:3828 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:512-445-6532
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2009-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105731703Medicaid
TX105731701Medicaid
TX8D0603Medicare PIN
TX883343Medicare PIN
TX105731703Medicaid