Provider Demographics
NPI:1083685291
Name:FAUDERE, CRYSTAL D (DO)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:D
Last Name:FAUDERE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 W CENTRAL AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2184
Mailing Address - Country:US
Mailing Address - Phone:316-321-2010
Mailing Address - Fax:
Practice Address - Street 1:700 W CENTRAL AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2184
Practice Address - Country:US
Practice Address - Phone:316-321-2010
Practice Address - Fax:316-321-8871
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS530512207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200331140AMedicaid
KS200331140AMedicaid
KS104790Medicare ID - Type Unspecified