Provider Demographics
NPI:1528302064
Name:FOX, CRYSTAL ANN (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:ANN
Last Name:FOX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:ANN
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7 WYNMOOR DR
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8003
Mailing Address - Country:US
Mailing Address - Phone:708-834-4340
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3175
Practice Address - Country:US
Practice Address - Phone:207-662-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-21
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125062499207R00000X, 208000000X
MEMD22907208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics