Provider Demographics
NPI:1255306312
Name:CRANDALL, BENJAMIN MERRICK (DO)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:MERRICK
Last Name:CRANDALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 W CANNON ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3146
Mailing Address - Country:US
Mailing Address - Phone:817-321-0937
Mailing Address - Fax:
Practice Address - Street 1:815 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2224
Practice Address - Country:US
Practice Address - Phone:817-321-0937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL48962085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54N97CROtherBLUE CROSS/BLUE SHIELD OF MINNESOTA
WI43549900Medicaid
MN182129OtherUCARE
MN300004758Medicare PIN
MNH88485Medicare UPIN
MN300004760Medicare PIN
MN300004759Medicare PIN
MN960371054237OtherPREFERRED ONE
MNHP93717OtherHEALTHPARTNERS