Healthcare Provider Details

I. General information

NPI: 1013987767
Provider Name (Legal Business Name): STEPHEN KROCZEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 08/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 E COOLSPRING AVE
MICHIGAN CITY IN
46360-6312
US

IV. Provider business mailing address

1225 E COOLSPRING AVE
MICHIGAN CITY IN
46360-6312
US

V. Phone/Fax

Practice location:
  • Phone: 219-878-5034
  • Fax: 219-878-5002
Mailing address:
  • Phone: 219-878-5034
  • Fax: 219-878-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number01020134A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: