Provider Demographics
NPI:1578680914
Name:CRUTCHFIELD, KEVIN EDMOND (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:EDMOND
Last Name:CRUTCHFIELD
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 1:12513 BRACKEN HILL LN
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-1116
Mailing Address - Country:US
Mailing Address - Phone:410-601-9515
Mailing Address - Fax:410-601-8905
Practice Address - Street 1:360 ESSEX ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-8550
Practice Address - Country:US
Practice Address - Phone:551-996-8100
Practice Address - Fax:551-996-4140
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA082488002084N0400X, 2084V0102X
VA01010448922084N0400X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG61573Medicare UPIN
NJ112520AJBMedicare PIN