Provider Demographics
NPI:1528253572
Name:MICHAEL N KRUTZIK MD A MEDICAL CORPORATION
Entity type:Organization
Organization Name:MICHAEL N KRUTZIK MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:KRUTZIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-352-6766
Mailing Address - Street 1:528 G ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-2411
Mailing Address - Country:US
Mailing Address - Phone:760-344-6355
Mailing Address - Fax:
Practice Address - Street 1:790 W ORANGE AVE STE C
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-3274
Practice Address - Country:US
Practice Address - Phone:760-352-6766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66632207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666320Medicaid
CA1447290168OtherINDIVIDUAL NPI
CAW21393Medicare PIN