Provider Demographics
NPI:1811906522
Name:CRANDALL, DAVID BRUCE JR (DO)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRUCE
Last Name:CRANDALL
Suffix:JR
Gender:M
Credentials:DO
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Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC, ATTN: CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:315-772-4025
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC, ATTN: CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV1993207P00000X
IN02003945207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400058043Medicare PIN
VAD000Medicare UPIN