Provider Demographics
NPI:1104838036
Name:CREVELLO, ALBERT JAMES JR (MD)
Entity Type:Individual
Prefix:MR
First Name:ALBERT
Middle Name:JAMES
Last Name:CREVELLO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:243 GREEN VALLEY RD STE E
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019-3133
Mailing Address - Country:US
Mailing Address - Phone:831-722-8807
Mailing Address - Fax:831-722-8809
Practice Address - Street 1:243 GREEN VALLEY RD STE E
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019-3133
Practice Address - Country:US
Practice Address - Phone:831-722-8807
Practice Address - Fax:831-722-8809
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23870207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A238700Medicaid
CA00A238700Medicare ID - Type Unspecified
CA00A238700Medicaid