Healthcare Provider Details

I. General information

NPI: 1497920995
Provider Name (Legal Business Name): MATTHEW DAVID KRASUCKI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W FLORIST AVE UNIT 203
GLENDALE WI
53209-3800
US

IV. Provider business mailing address

N54W26176 BODEN LN
SUSSEX WI
53089-4269
US

V. Phone/Fax

Practice location:
  • Phone: 414-649-7909
  • Fax:
Mailing address:
  • Phone: 630-995-1130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number54586-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number54586-020
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: