Provider Demographics
NPI:1063478071
Name:MCCRARY, KEVIN WAYE (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WAYE
Last Name:MCCRARY
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 1:1103 MARIGOLD LN
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-2844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 E MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-5580
Practice Address - Country:US
Practice Address - Phone:903-315-2072
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK51552085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84711SOtherBLUE CROSS BLUE SHIELD TX
TX012079OtherTX KIDNEY HEALTH
TX118644OtherCHIP PROGRAM
TXMDK5155OtherWORKERS COMP
TXP00048096OtherTRAVELER MEDICARE
TX752961826A009OtherCHAMPUS
TX84711SOtherBLUE CROSS BLUE SHIELD TX
TX118644OtherCHIP PROGRAM