Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207W00000X | Ophthalmologist | 01020134A | IN |
NPI | 1013987767 |
---|---|
Provider Name | Stephen Kroczek |
First Address | Michigan City, IN 46360-6312 |
Second Address | Michigan City, IN 46360-6312 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/01/2006 |
Last Update Date | 08/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
100261620 | (05) | IN |
B29007 | (02) |