Basic Information
| Provider Information | |||||||||
| NPI: | 1285600262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRUEGER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | TIMOTHY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268838 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194400 | ||||||||
| FaxNumber: | 9186194601 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 S SAINT LOUIS AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741205440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194400 | ||||||||
| FaxNumber: | 9186194601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 08/30/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E4605 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25027 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5N390 | 01 | AR | BLUE CROSS/BLUE SHIELD | OTHER | P00260757 | 01 | AR | RAILROAD MEDICARE | OTHER | 05110013100 | 01 | AR | QUALCHOICE | OTHER | 1285600262 | 05 | IA | MEDICAID | 158169001 | 05 | AR | MEDICAID | 8436548 | 01 | AR | CIGNA | OTHER | 200102360B | 05 | OK | MEDICAID |