Provider Demographics
NPI:1043216625
Name:CROWHURST, JEFFREY A (DPM)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:CROWHURST
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 POLARIS CIR
Mailing Address - Street 2:
Mailing Address - City:OTTAWA
Mailing Address - State:IL
Mailing Address - Zip Code:61350-1683
Mailing Address - Country:US
Mailing Address - Phone:815-434-1900
Mailing Address - Fax:815-434-0933
Practice Address - Street 1:1703 POLARIS CIR
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350-1683
Practice Address - Country:US
Practice Address - Phone:815-434-1900
Practice Address - Fax:815-434-0933
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL016003179213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL60101269OtherBLUE CROSS
480025582OtherRAILROAD MEDICARE
IL016003179Medicaid
IL933820Medicare PIN
480025582OtherRAILROAD MEDICARE
IL60101269OtherBLUE CROSS