Provider Demographics
NPI:1962409896
Name:CRANDALL, VALERIE JEAN (MD)
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:JEAN
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VALERIE
Other - Middle Name:CRANDALL
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 162264
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-2264
Mailing Address - Country:US
Mailing Address - Phone:941-792-2020
Mailing Address - Fax:239-275-6178
Practice Address - Street 1:820 W SUGARLAND HWY
Practice Address - Street 2:
Practice Address - City:CLEWISTON
Practice Address - State:FL
Practice Address - Zip Code:33440-2700
Practice Address - Country:US
Practice Address - Phone:941-792-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34980207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067150900Medicaid