Provider Demographics
NPI:1346307030
Name:CREW, EARL DOUGLAS JR (OD)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:DOUGLAS
Last Name:CREW
Suffix:JR
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 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:866-795-4020
Practice Address - Street 1:15196 US HIGHWAY 19 S
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31757-4820
Practice Address - Country:US
Practice Address - Phone:229-228-4770
Practice Address - Fax:229-225-9060
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT000901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00207303A3OtherMCAID
GA00207303B3Medicaid
GA100013OtherAVESIS
GA00207303A3OtherMCAID
GA0729670001Medicare NSC