Provider Demographics
NPI:1992738967
Name:KRUCKE, GUS W (MD)
Entity type:Individual
Prefix:
First Name:GUS
Middle Name:W
Last Name:KRUCKE
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:PO BOX 301448
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75303-1448
Mailing Address - Country:US
Mailing Address - Phone:713-500-3500
Mailing Address - Fax:
Practice Address - Street 1:6410 FANNIN ST
Practice Address - Street 2:600
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-3000
Practice Address - Country:US
Practice Address - Phone:832-325-7100
Practice Address - Fax:713-512-2262
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH8942207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F8250OtherBCBS
TX150198301Medicaid
TX110235484Medicare PIN
TX8F8250OtherBCBS
TX150198301Medicaid