Provider Demographics
NPI:1003828633
Name:CRECELIUS, WILLIAM D (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:D
Last Name:CRECELIUS
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 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-834-3593
Mailing Address - Fax:760-674-3845
Practice Address - Street 1:72780 COUNTRY CLUB DR STE 203
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-4150
Practice Address - Country:US
Practice Address - Phone:760-834-3593
Practice Address - Fax:760-674-3845
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28795207P00000X, 208D00000X
CAG138326207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64287956Medicaid
KY000000048676OtherANTHEM
KY2433207000OtherPASSPORT ADVANTAGE
KY10523140OtherPASSPORT
IN200009610Medicaid
KYF40220Medicare UPIN
KY64287956Medicaid
IN200009610Medicaid