Provider Demographics
NPI:1326108945
Name:CRITCHLOW, JOHN THOMAS (M D)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:CRITCHLOW
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3065 WILLIAM ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CAPE GIRARDEAU
Mailing Address - State:MO
Mailing Address - Zip Code:63703-6393
Mailing Address - Country:US
Mailing Address - Phone:573-651-1882
Mailing Address - Fax:573-334-5302
Practice Address - Street 1:3065 WILLIAM ST
Practice Address - Street 2:SUITE 105
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63703-6393
Practice Address - Country:US
Practice Address - Phone:573-651-1882
Practice Address - Fax:573-334-5302
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6605174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201100237Medicaid
MO201100237Medicaid
MOA11191Medicare UPIN