Healthcare Provider Details

I. General information

NPI: 1053979674
Provider Name (Legal Business Name): STEPHEN ROBERT KRUGER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/10/2024
Certification Date: 07/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W EATON AVE
TRACY CA
95376-3420
US

IV. Provider business mailing address

PO BOX 255228
SACRAMENTO CA
95865-5228
US

V. Phone/Fax

Practice location:
  • Phone: 209-830-4075
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number315634
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB11240400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A22402
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: