Healthcare Provider Details

I. General information

NPI: 1982592788
Provider Name (Legal Business Name): DIRK MITCHELL KROG I DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12303 DE PAUL DR
BRIDGETON MO
63044-2512
US

IV. Provider business mailing address

28602 510TH AVE
HENNING MN
56551-9319
US

V. Phone/Fax

Practice location:
  • Phone: 314-344-6000
  • Fax:
Mailing address:
  • Phone: 218-831-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: