Provider Demographics
NPI:1528123965
Name:CRENSHAW, DARYL O (MD)
Entity type:Individual
Prefix:DR
First Name:DARYL
Middle Name:O
Last Name:CRENSHAW
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 1:334 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5533
Mailing Address - Country:US
Mailing Address - Phone:229-227-1595
Mailing Address - Fax:229-227-0530
Practice Address - Street 1:334 SMITH AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-5533
Practice Address - Country:US
Practice Address - Phone:229-227-1595
Practice Address - Fax:229-227-1385
Is Sole Proprietor?:No
Enumeration Date:2006-12-26
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA56036207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA720019553HMedicaid
GA720019553DMedicaid
GA720019553AMedicaid
GA720019553IMedicaid
GA720019553FMedicaid
GA720019553BMedicaid
GA720019553CMedicaid
GA720019553GMedicaid
GA720019553EMedicaid
GA720019553GMedicaid
GA720019553IMedicaid