Provider Demographics
NPI:1255315644
Name:CROUCH, DONOVAN L (OD)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:L
Last Name:CROUCH
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 1:701 WINTHROP CIR
Mailing Address - Street 2:
Mailing Address - City:STORM LAKE
Mailing Address - State:IA
Mailing Address - Zip Code:50588-2747
Mailing Address - Country:US
Mailing Address - Phone:712-732-2456
Mailing Address - Fax:
Practice Address - Street 1:600 ONTARIO ST
Practice Address - Street 2:
Practice Address - City:STORM LAKE
Practice Address - State:IA
Practice Address - Zip Code:50588-1845
Practice Address - Country:US
Practice Address - Phone:712-732-3233
Practice Address - Fax:712-732-1866
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1470152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1082362Medicaid
IAT71262Medicare UPIN
IA1082362Medicaid