Healthcare Provider Details

I. General information

NPI: 1629029202
Provider Name (Legal Business Name): MARY V. KRUEGER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 10/25/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALEXANDER T. AUGUSTA MILITARY MEDICAL CENTER 9300 DEWITT LOOP
FORT BELVOIR VA
22060
US

IV. Provider business mailing address

7884 TRAIN CT
DUNN LORING VA
22027-1172
US

V. Phone/Fax

Practice location:
  • Phone: 571-231-3224
  • Fax:
Mailing address:
  • Phone: 910-644-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number38925-21
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38925-021
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: