Provider Demographics
NPI:1932104890
Name:KROENER, JOHN M (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:KROENER
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 1:3601 VISTA WAY STE 203
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-4559
Mailing Address - Country:US
Mailing Address - Phone:760-724-5352
Mailing Address - Fax:760-724-5447
Practice Address - Street 1:3601 VISTA WAY STE 203
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4559
Practice Address - Country:US
Practice Address - Phone:760-724-5352
Practice Address - Fax:760-724-5447
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2016-11-01
Deactivation Date:2006-03-18
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
CAG352622086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG352620Medicaid
CAA46282Medicare UPIN
CAG352620Medicaid