Provider Demographics
NPI:1477556280
Name:CROUCH, CHARLES ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALLEN
Last Name:CROUCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1200 1ST AVE E
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPENCER
Mailing Address - State:IA
Mailing Address - Zip Code:51301-4342
Mailing Address - Country:US
Mailing Address - Phone:712-262-7511
Mailing Address - Fax:712-262-3658
Practice Address - Street 1:1200 1ST AVE E
Practice Address - Street 2:SUITE C
Practice Address - City:SPENCER
Practice Address - State:IA
Practice Address - Zip Code:51301-4342
Practice Address - Country:US
Practice Address - Phone:712-262-7511
Practice Address - Fax:712-262-3658
Is Sole Proprietor?:No
Enumeration Date:2005-05-24
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA285702085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA5118760Medicaid
IAF92996Medicare UPIN
IA5118760Medicaid