Provider Demographics
NPI:1740347830
Name:KRUSE, JOHN SAMUEL (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SAMUEL
Last Name:KRUSE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 A HARTFORD ST.
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94114-2013
Mailing Address - Country:US
Mailing Address - Phone:415-701-8844
Mailing Address - Fax:
Practice Address - Street 1:45 HARTFORD ST # A
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-2013
Practice Address - Country:US
Practice Address - Phone:415-701-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0744372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG074437OtherSTATE MEDICAL LICENSE
CA00G744370Medicare ID - Type UnspecifiedPROVIDER NUMBER
CAG074437OtherSTATE MEDICAL LICENSE