Provider Demographics
NPI:1881800902
Name:KROUK, MARIANNE G (DO)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:G
Last Name:KROUK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5031 HARBORTOWN LANE
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4650
Mailing Address - Country:US
Mailing Address - Phone:239-362-1339
Mailing Address - Fax:239-362-1340
Practice Address - Street 1:5294 SUMMERLIN COMMONS WAY
Practice Address - Street 2:SUITE 1201
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-2164
Practice Address - Country:US
Practice Address - Phone:239-362-1339
Practice Address - Fax:239-362-1340
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS101992084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA414623Medicaid
FL279276100Medicaid
PA414623Medicaid