Provider Demographics
NPI:1508987371
Name:CRUDO, JEFFREY JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:CRUDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 S COAST HWY STE 206
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2972
Mailing Address - Country:US
Mailing Address - Phone:949-715-6890
Mailing Address - Fax:
Practice Address - Street 1:1100 S COAST HWY STE 206
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2972
Practice Address - Country:US
Practice Address - Phone:949-715-6890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC128508207R00000X, 208M00000X
NV12581207R00000X
FLME113261208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508987371Medicaid
NV1508987371Medicaid
NVG96652Medicare UPIN
CA1508987371Medicaid