Provider Demographics
NPI:1164547048
Name:CRAWLEY, KENNETH ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROBERT
Last Name:CRAWLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 N GRANVILLE AVE STE L4
Mailing Address - Street 2:MUNCIE MALL
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-1254
Mailing Address - Country:US
Mailing Address - Phone:765-286-5977
Mailing Address - Fax:765-286-5988
Practice Address - Street 1:3501 N GRANVILLE AVE STE L4
Practice Address - Street 2:MUNCIE MALL
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1254
Practice Address - Country:US
Practice Address - Phone:765-286-5977
Practice Address - Fax:765-286-5988
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001737152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1737OtherVISION BENEFITS OF AMERIC
43106OtherCLARITY
217779OtherCLARITY
IN000000269589OtherBLUE CROSS/BLUE SHIELD
IN000000269582OtherBLUECROSS/BLUE SHIELD
919893OtherEYEMED
IN990002951OtherRAILROAD MEDICARE
10609OtherDAVIS
INP00083065OtherRAI;ROAD MEDICARE
918567OtherEYEMED
918567OtherEYEMED
IN149340Medicare ID - Type Unspecified
IN147600Medicare PIN