Provider Demographics
NPI:1093846479
Name:CROUSE, CHARLES WILLIAM (CRT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:CROUSE
Suffix:
Gender:M
Credentials:CRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 MAPLE ST
Mailing Address - Street 2:801 MAPLE STREETT
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-2302
Mailing Address - Country:US
Mailing Address - Phone:650-347-1880
Mailing Address - Fax:650-342-8379
Practice Address - Street 1:801 MAPLE ST
Practice Address - Street 2:801 MAPLE STREET
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2302
Practice Address - Country:US
Practice Address - Phone:650-347-1880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHT3605335V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31682ZMedicaid
CAZZZ31682ZMedicare ID - Type Unspecified