Healthcare Provider Details

I. General information

NPI: 1891993150
Provider Name (Legal Business Name): DAVID WILLIAM KRUSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 E KATELLA AVE STE 400
ANAHEIM CA
92806-5972
US

IV. Provider business mailing address

444 S SAN VICENTE BLVD STE 603
LOS ANGELES CA
90048-4178
US

V. Phone/Fax

Practice location:
  • Phone: 310-423-4566
  • Fax: 310-423-9958
Mailing address:
  • Phone: 310-423-4566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA92859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: