Healthcare Provider Details

I. General information

NPI: 1093177321
Provider Name (Legal Business Name): KEVIN KRUGHOFF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: N/A N/A N/A MD

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 HARTMAN LN
SPRINGFIELD OR
97477-1118
US

IV. Provider business mailing address

2876 LONGFELLOW PL APT 251
EUGENE OR
97408-7465
US

V. Phone/Fax

Practice location:
  • Phone: 541-736-2934
  • Fax:
Mailing address:
  • Phone: 720-317-5902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2021-00685
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD209558
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: