Provider Demographics
NPI:1215122304
Name:CRUM, MARY MELITA (OPTICIAN)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:MELITA
Last Name:CRUM
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11266 W FLORISSANT AVE
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63033-6741
Mailing Address - Country:US
Mailing Address - Phone:314-838-3539
Mailing Address - Fax:314-838-0633
Practice Address - Street 1:11266 W FLORISSANT AVE
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-6741
Practice Address - Country:US
Practice Address - Phone:314-838-3539
Practice Address - Fax:314-838-0633
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOB0057567A156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
0172720001Medicare NSC