Provider Demographics
NPI:1417971094
Name:CRANE, GWENDOLYN ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:GWENDOLYN
Middle Name:ANN
Last Name:CRANE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 44TH AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2552
Mailing Address - Country:US
Mailing Address - Phone:228-868-4006
Mailing Address - Fax:228-822-2461
Practice Address - Street 1:1304 44TH AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2552
Practice Address - Country:US
Practice Address - Phone:228-868-4006
Practice Address - Fax:228-822-2461
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14316207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0116605Medicaid
MS$$$$$$$$$OtherBLUE CROSS
MSE86283Medicare UPIN