Provider Demographics
NPI:1891800561
Name:KRUSE, DIANA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:KRUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 PHILLIPS BLVD
Mailing Address - Street 2:
Mailing Address - City:SAUK CITY
Mailing Address - State:WI
Mailing Address - Zip Code:53583-1523
Mailing Address - Country:US
Mailing Address - Phone:608-644-0109
Mailing Address - Fax:608-644-0112
Practice Address - Street 1:208 PHILLIPS BLVD
Practice Address - Street 2:
Practice Address - City:SAUK CITY
Practice Address - State:WI
Practice Address - Zip Code:53583-1523
Practice Address - Country:US
Practice Address - Phone:608-644-0109
Practice Address - Fax:608-644-0112
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI21754207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30384700Medicaid
WI000057114Medicare ID - Type Unspecified
WIB54352Medicare UPIN