Provider Demographics
NPI:1356433288
Name:KRUTT, KENNETH A (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:KRUTT
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 1:37 BROADWAY
Mailing Address - Street 2:LAHEY ARLINGTON
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-5552
Mailing Address - Country:US
Mailing Address - Phone:781-641-0100
Mailing Address - Fax:781-744-7132
Practice Address - Street 1:37 BROADWAY
Practice Address - Street 2:37 BROADWAY
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02474-5552
Practice Address - Country:US
Practice Address - Phone:781-641-0100
Practice Address - Fax:781-744-7132
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA55836207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110044053AMedicaid
MA110044053AMedicaid
MAA58729Medicare UPIN