Healthcare Provider Details

I. General information

NPI: 1003099771
Provider Name (Legal Business Name): JOHN B. KRUEGER, MD, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9660 S 1300 E
SANDY UT
84094-3762
US

IV. Provider business mailing address

23 SNOWSTAR LN
SANDY UT
84092-4800
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-9753
  • Fax: 801-253-9754
Mailing address:
  • Phone: 801-253-9753
  • Fax: 801-253-9754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number275855-1205
License Number StateUT

VIII. Authorized Official

Name: DR. JOHN B KRUEGER
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 801-253-9753