Provider Demographics
NPI:1285723460
Name:KRACAW, KURT E (MD)
Entity type:Individual
Prefix:
First Name:KURT
Middle Name:E
Last Name:KRACAW
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 1:3340 E GOLDSTONE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-452-8000
Mailing Address - Fax:208-452-8055
Practice Address - Street 1:910 NW 16TH ST
Practice Address - Street 2:STE 101
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619
Practice Address - Country:US
Practice Address - Phone:208-452-8000
Practice Address - Fax:208-452-8055
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM13115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1467963496Medicaid
NV2007018Medicaid
NVMD6809Medicare ID - Type Unspecified