1265420020 NPI number — DR. ELENA KRUGLYAK MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265420020 NPI number — DR. ELENA KRUGLYAK MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

KRUGLYAK

Provider First Name:

ELENA

Provider Middle Name:

Provider Name Prefix Text:

DR.

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

KRUGLYAK

Provider Other First Name:

ELENA

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

5

NPI Number:

1265420020

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

07/31/2024

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 102222

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

ATLANTA

Provider Business Mailing Address State Name:

GA

Provider Business Mailing Address Postal Code:

30368-2222

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

239-274-8200

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

5130 LINTON BLVD STE B4

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

DELRAY BEACH

Provider Business Practice Location Address State Name:

FL

Provider Business Practice Location Address Postal Code:

33484-6595

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

561-808-0098

Provider Business Practice Location Address Fax Number:

561-496-0592

Provider Enumeration Date:

10/06/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 174400000X , with the licence number:  ME68735 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RH0000X , with the licence number: ME68735 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 207RX0202X , with the licence number: ME68735 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 264956000 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: 27290 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 5475027 . This is a "AETNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 252889 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: DELRAY456 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 102794200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
• Identifier: P954880 . This is a "OPTIMUM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 1255024 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 6550599 . This is a "CIGNA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: 6664 . This is a "DIMENSION HEALTH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: QMP000003849305 . This is a "MOLINA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
• Identifier: P1001984 . This is a "FREEDOM" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".