Provider Demographics
NPI:1104125780
Name:CRANDALL, KEITH ROBERT (DPM)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ROBERT
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 STAFFORD DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-0839
Mailing Address - Country:US
Mailing Address - Phone:903-941-9247
Mailing Address - Fax:888-503-2519
Practice Address - Street 1:1605 STAFFORD DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-0839
Practice Address - Country:US
Practice Address - Phone:903-941-9247
Practice Address - Fax:888-503-2519
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHBN6420119-057356213ES0103X
TX2066213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery