Provider Demographics
NPI:1932192226
Name:KRUCKNER, DOUGLAS LEE (MD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LEE
Last Name:KRUCKNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:DOUG
Other - Middle Name:L
Other - Last Name:KRUCKNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:900 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:JULESBURG
Mailing Address - State:CO
Mailing Address - Zip Code:80737
Mailing Address - Country:US
Mailing Address - Phone:970-474-3323
Mailing Address - Fax:970-474-2461
Practice Address - Street 1:900 CEDAR ST
Practice Address - Street 2:
Practice Address - City:JULESBURG
Practice Address - State:CO
Practice Address - Zip Code:80737
Practice Address - Country:US
Practice Address - Phone:970-474-3323
Practice Address - Fax:970-474-2461
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1189207Q00000X
CO49376207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612683Medicare PIN