Basic Information
Provider Information
NPI: 1891993150
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KRUSE
FirstName: DAVID
MiddleName: WILLIAM
NamePrefix:  
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 280 S MAIN ST
Address2: SUITE 200
City: ORANGE
State: CA
PostalCode: 928683852
CountryCode: US
TelephoneNumber: 7146344567
FaxNumber: 7146344569
Practice Location
Address1: 280 S MAIN ST
Address2: SUITE 200
City: ORANGE
State: CA
PostalCode: 928683852
CountryCode: US
TelephoneNumber: 7146344567
FaxNumber: 7146344569
Other Information
ProviderEnumerationDate: 07/10/2007
LastUpdateDate: 01/09/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207QS0010XA92859CAY Allopathic & Osteopathic PhysiciansFamily MedicineSports Medicine

No ID Information.


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