Provider Demographics
NPI:1386695609
Name:KRAUSE, MARK GRADWELL (DC)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:GRADWELL
Last Name:KRAUSE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 FLETCHER PKWY
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2134
Mailing Address - Country:US
Mailing Address - Phone:619-460-4465
Mailing Address - Fax:
Practice Address - Street 1:2345 FLETCHER PKWY
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2134
Practice Address - Country:US
Practice Address - Phone:619-460-4465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor