Provider Demographics
NPI:1316990005
Name:CRADDOCK, ROBERT QUENTON (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:QUENTON
Last Name:CRADDOCK
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 1:513 BROOKWOOD BLVD
Mailing Address - Street 2:STE. 75
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-6862
Mailing Address - Country:US
Mailing Address - Phone:205-250-6805
Mailing Address - Fax:205-250-6580
Practice Address - Street 1:513 BROOKWOOD BLVD
Practice Address - Street 2:STE. 75
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6862
Practice Address - Country:US
Practice Address - Phone:205-250-6805
Practice Address - Fax:205-250-6580
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6319207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000005713Medicaid
AL000005713Medicaid
AL000005713Medicare PIN