Provider Demographics
NPI:1093749350
Name:CRAVEN, JAMES MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:MICHAEL
Last Name:CRAVEN
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 1:1050 W GRANADA BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-8154
Mailing Address - Country:US
Mailing Address - Phone:386-677-8808
Mailing Address - Fax:386-677-2134
Practice Address - Street 1:1050 W GRANADA BLVD
Practice Address - Street 2:SUITE 4
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8154
Practice Address - Country:US
Practice Address - Phone:386-677-8808
Practice Address - Fax:386-677-2134
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY25633207Y00000X, 207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA040016956OtherRR MEDICARE PIN
KY37903705OtherMEDICAID LAB GROUP
GACB5773OtherRR MEDICARE GROUP
KY4000501OtherMEDICARE LAB GROUP
KY64047475Medicaid
KY0091280Medicare ID - Type Unspecified
KY64047475Medicaid