Healthcare Provider Details

I. General information

NPI: 1598341026
Provider Name (Legal Business Name): JACQUELINE KRUGLYAKOVA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N WOLFE ST
BALTIMORE MD
21287-0005
US

IV. Provider business mailing address

2111 WISCONSIN AVE NW APT 414
WASHINGTON DC
20007-2226
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-2727
  • Fax:
Mailing address:
  • Phone: 310-993-4347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7231
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7231
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: