Provider Demographics
NPI:1285600262
Name:KRUEGER, JOHN TIMOTHY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TIMOTHY
Last Name:KRUEGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1925 WARRIOR WAY
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-3491
Mailing Address - Country:US
Mailing Address - Phone:580-421-4570
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1921 STONECIPHER DR
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-3439
Practice Address - Country:US
Practice Address - Phone:580-436-3980
Practice Address - Fax:580-421-6283
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE4605207Q00000X
OK25027207Q00000X
IA40607207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARP00260757OtherRAILROAD MEDICARE
AR05110013100OtherQUALCHOICE
IA1285600262Medicaid
AR5N390OtherBLUE CROSS/BLUE SHIELD
AR158169001Medicaid
AR8436548OtherCIGNA
OK200102360BMedicaid
ARP00260757OtherRAILROAD MEDICARE
ARH76930Medicare UPIN
IA1285600262Medicaid