Healthcare Provider Details

I. General information

NPI: 1871052704
Provider Name (Legal Business Name): JOHN JOSEPH KRUTSICK II DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 06/03/2024
Certification Date: 06/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21298 OLEAN BLVD
PORT CHARLOTTE FL
33952-6765
US

IV. Provider business mailing address

21298 OLEAN BLVD
PORT CHARLOTTE FL
33952-6765
US

V. Phone/Fax

Practice location:
  • Phone: 941-629-1181
  • Fax:
Mailing address:
  • Phone: 941-629-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS17419
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS17419
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: