Provider Demographics
NPI:1215996335
Name:KROUS, LORRY C (MD)
Entity type:Individual
Prefix:
First Name:LORRY
Middle Name:C
Last Name:KROUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LORRY
Other - Middle Name:C
Other - Last Name:STAYTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4722 N 24TH ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-4800
Mailing Address - Country:US
Mailing Address - Phone:877-737-4546
Mailing Address - Fax:
Practice Address - Street 1:4300 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8304
Practice Address - Country:US
Practice Address - Phone:405-579-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21271208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100097570AMedicaid
OK100364Medicare PIN