Provider Demographics
NPI:1891466629
Name:KROSTA, HEINZ JURGEN (RT(R))
Entity Type:Individual
Prefix:
First Name:HEINZ
Middle Name:JURGEN
Last Name:KROSTA
Suffix:
Gender:M
Credentials:RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 S WHITE MOUNTAIN RD TRLR 82
Mailing Address - Street 2:
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7652
Mailing Address - Country:US
Mailing Address - Phone:936-994-2228
Mailing Address - Fax:
Practice Address - Street 1:3860 S WHITE MOUNTAIN RD TRLR 82
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7652
Practice Address - Country:US
Practice Address - Phone:936-994-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2369282085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1206316108OtherVA