Provider Demographics
NPI:1437257813
Name:CRANDALL, EMILY (MD)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:CRANDALL
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 1:1807 WILSHIRE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5652
Mailing Address - Country:US
Mailing Address - Phone:310-453-3452
Mailing Address - Fax:310-453-2563
Practice Address - Street 1:1807 WILSHIRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5652
Practice Address - Country:US
Practice Address - Phone:310-453-3452
Practice Address - Fax:310-453-2563
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43175174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG43175Medicare ID - Type Unspecified