Provider Demographics
NPI:1316019441
Name:GANGWISH, CRAIG ALLEN (DC)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:ALLEN
Last Name:GANGWISH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4239 SUMMER AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38122-4046
Mailing Address - Country:US
Mailing Address - Phone:901-763-2225
Mailing Address - Fax:901-682-4569
Practice Address - Street 1:4239 SUMMER AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38122-4046
Practice Address - Country:US
Practice Address - Phone:901-763-2225
Practice Address - Fax:901-682-4569
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000000782111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3676193Medicare ID - Type Unspecified
TNU28749Medicare UPIN