Provider Demographics
NPI:1417921362
Name:CRICKENBERGER, DALLAS PAYNE (MD)
Entity Type:Individual
Prefix:
First Name:DALLAS
Middle Name:PAYNE
Last Name:CRICKENBERGER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 RIVERSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4955
Mailing Address - Country:US
Mailing Address - Phone:540-725-1226
Mailing Address - Fax:540-857-5306
Practice Address - Street 1:3 RIVERSIDE CIR
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4955
Practice Address - Country:US
Practice Address - Phone:540-725-1226
Practice Address - Fax:540-857-5306
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-017904207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417921362OtherVIRGINIA HEALTH NETWORK
VA1417921362OtherVA PREMIER
VA1417921362OtherGATEWAY
VA1417921362OtherAETNA
VA1417921362OtherMAJESTACARE
VA1417921362OtherINTOTAL
VA1417921362OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VA540506332004OtherTRICARE/CHAMPUS
VA1417921362OtherANTHEM
VA1417921362OtherHEALTHKEEPERS
VA1417921362OtherHEALTHKEEPERS PLUS
VA1417921362OtherCIGNA
VA1417921362OtherUMWA
VA1417921362OtherHUMANA MEDICARE
VA1417921362OtherUNITED HEALTHCARE
VAP200030655OtherRAILROAD MEDICARE
VA1417921362OtherOPTIMA HEALTH PLAN
VA1417921362Medicaid
VA0097064000OtherMEDICAID OF WEST VIRGINIA
VA371194700OtherBLACK LUNG
VAB07555Medicare UPIN
VA200000978Medicare PIN