Provider Demographics
NPI:1114414513
Name:CRAIG, ETHAN KENJI (MD)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:KENJI
Last Name:CRAIG
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 1:111 N MAPLEMERE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-3182
Mailing Address - Country:US
Mailing Address - Phone:716-833-7112
Mailing Address - Fax:
Practice Address - Street 1:111 N MAPLEMERE RD STE 100
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-3182
Practice Address - Country:US
Practice Address - Phone:716-833-7112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME162962208600000X
NY327603208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery