Provider Demographics
NPI:1326037268
Name:AMOS BOYKIN, CRYSTAL
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:AMOS BOYKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:F
Other - Last Name:AMOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2555 CREEKWOOD CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45504-4056
Mailing Address - Country:US
Mailing Address - Phone:937-327-0552
Mailing Address - Fax:
Practice Address - Street 1:2555 CREEKWOOD CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45504-4056
Practice Address - Country:US
Practice Address - Phone:937-327-0552
Practice Address - Fax:937-327-0556
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-06-3808-A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0978278Medicaid
OHF81761Medicare UPIN
OHAM0762895Medicare ID - Type Unspecified