Provider Demographics
NPI:1013294883
Name:KRUK, GARY CRAIG (BA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:CRAIG
Last Name:KRUK
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 TRIAD VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-2967
Mailing Address - Country:US
Mailing Address - Phone:405-321-7331
Mailing Address - Fax:405-364-6058
Practice Address - Street 1:1251 TRIAD VILLAGE DR
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-2967
Practice Address - Country:US
Practice Address - Phone:405-321-7331
Practice Address - Fax:405-364-6058
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-08
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200268830Medicaid