Basic Information
| Provider Information | |||||||||
| NPI: | 1972579696 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KROGSTAD | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 E FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | OLIVIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562774213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205231460 | ||||||||
| FaxNumber: | 3205238349 | ||||||||
| Practice Location | |||||||||
| Address1: | 611 E FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | OLIVIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562774213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3205231460 | ||||||||
| FaxNumber: | 3205238349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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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 | 26657 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 032708500 | 05 | MN | MEDICAID |