Provider Demographics
NPI:1275945305
Name:CREWS, JACQUELYN FARYN (MD)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:FARYN
Last Name:CREWS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1699 SW 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1158
Mailing Address - Country:US
Mailing Address - Phone:352-265-3604
Mailing Address - Fax:352-627-4892
Practice Address - Street 1:5528 NW 43RD ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-3301
Practice Address - Country:US
Practice Address - Phone:352-265-3604
Practice Address - Fax:352-627-4892
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL131145208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL131145OtherMEDICAL LICENSE
FL020389300Medicaid