Provider Demographics
NPI:1205931417
Name:KRUSE, JERRY ELLIOTT (MD)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:ELLIOTT
Last Name:KRUSE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1303 MCCULLOUGH AVE
Mailing Address - Street 2:SUITE #561
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5668
Mailing Address - Country:US
Mailing Address - Phone:210-227-9376
Mailing Address - Fax:210-227-0916
Practice Address - Street 1:1303 MCCULLOUGH AVE
Practice Address - Street 2:SUITE #561
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-5668
Practice Address - Country:US
Practice Address - Phone:210-227-9376
Practice Address - Fax:210-227-0916
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE4464208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX101951502Medicaid
TX816414Medicare ID - Type Unspecified
TXC18060Medicare UPIN