Provider Demographics
NPI:1063480119
Name:CASSIDY, CRAIG R (DO)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:R
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W UNIVERSITY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201
Mailing Address - Country:US
Mailing Address - Phone:480-833-0014
Mailing Address - Fax:480-835-6821
Practice Address - Street 1:160 W UNIVERSITY
Practice Address - Street 2:SUITE 1
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-833-0014
Practice Address - Fax:480-835-6821
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-14
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1769207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ237314Medicaid
C98182Medicare UPIN