Provider Demographics
NPI:1366459398
Name:CROSSON, BRUCE A (PHD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:CROSSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:A
Other - Last Name:CROSSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-6617
Mailing Address - Fax:352-273-6156
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:BOX 100371
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-6617
Practice Address - Fax:352-273-6156
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4202103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74477WMedicare PIN
FL74477YMedicare PIN
FL74477ZMedicare PIN