Provider Demographics
NPI:1992719942
Name:TOLLESON, CRAIG WALLIS (MD)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:WALLIS
Last Name:TOLLESON
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 1:2187 N VICKEY ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-6106
Mailing Address - Country:US
Mailing Address - Phone:928-714-6401
Mailing Address - Fax:928-714-6408
Practice Address - Street 1:2187 N VICKEY ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-6106
Practice Address - Country:US
Practice Address - Phone:928-714-6401
Practice Address - Fax:928-714-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT109572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ231772OtherAHCCCS
MT0000092216OtherBLUE CROSS/SHIELD OF MONT
AZ36928OtherARIZONA MEDICAL BOARD
AZ36928OtherARIZONA MEDICAL BOARD
AZ36928OtherARIZONA MEDICAL BOARD
AZ231772OtherAHCCCS