Healthcare Provider Details

I. General information

NPI: 1912010117
Provider Name (Legal Business Name): LOTHAR KRUEGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 A1A BEACH BLVD
ST AUGUSTINE FL
32080
US

IV. Provider business mailing address

191 CREEKSIDE DR
ST AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-9104
  • Fax: 904-471-3386
Mailing address:
  • Phone: 904-797-3882
  • Fax: 904-471-3386

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME48836
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: