Provider Demographics
NPI: | 1497890115 |
---|---|
Name: | CROUCH, JASON MICHAEL (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JASON |
Middle Name: | MICHAEL |
Last Name: | CROUCH |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 806 MANVEL AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | CHANDLER |
Mailing Address - State: | OK |
Mailing Address - Zip Code: | 74834-3858 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 405-258-9955 |
Mailing Address - Fax: | 405-258-9930 |
Practice Address - Street 1: | 806 MANVEL AVE |
Practice Address - Street 2: | |
Practice Address - City: | CHANDLER |
Practice Address - State: | OK |
Practice Address - Zip Code: | 74834-3858 |
Practice Address - Country: | US |
Practice Address - Phone: | 405-258-9955 |
Practice Address - Fax: | 405-258-9930 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2007-02-20 |
Last Update Date: | 2013-03-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OK | 4290 | 207Q00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OK | 200116510 A | Other | MEDICAID # FOR CROUCH FAMILY MEDICINE (CLINIC) |
37D1067992 | Other | CLIA # FOR CROUCH FAMILY MEDICINE LAB (CLIA-WAIVED LAB) | |
9060050 | Other | AETNA PIN | |
1618242 | Other | COVENTRY HEALTH CARE PROVIDER ID # | |
OK | 200116510A | Medicaid | |
6147210001 | Other | DURABLE MEDICAL EQUIPMENT (DME) PTAN | |
P00465778 | Other | RAILROAD MEDICARE PT B PTAN | |
OK | 200116520A | Medicaid | |
300522328 | Other | MEDICARE # FOR CROUCH FAMILY MEDICINE (CLINIC) | |
DG9878 | Other | RAILROAD MEDICARE PT B GROUP NUMBER | |
1609093228 | Other | NPI FOR CROUCH FAMILY MEDICINE PC (ORGANIZATION NPI) | |
243722101 | Other | MEDICARE # FOR JASON CROUCH, D.O. | |
1497890115 | Other | NPI FOR JASON CROUCH, D.O. | |
OK | 200116520 A | Other | MEDICAID # FOR JASON CROUCH, D.O. |
4474235 | Other | CIGNA HEALTHCARE PROVIDER # | |
9060050 | Other | AETNA PIN | |
243722101 | Other | MEDICARE # FOR JASON CROUCH, D.O. | |
37D1067992 | Other | CLIA # FOR CROUCH FAMILY MEDICINE LAB (CLIA-WAIVED LAB) | |
4474235 | Other | CIGNA HEALTHCARE PROVIDER # | |
300522328 | Other | MEDICARE # FOR CROUCH FAMILY MEDICINE (CLINIC) | |
P00465778 | Medicare PIN |