Provider Demographics
NPI:1619096278
Name:CRANDALL, MARK ALAN (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:CRANDALL
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 1:473 W 12TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1252
Mailing Address - Country:US
Mailing Address - Phone:614-293-8000
Mailing Address - Fax:
Practice Address - Street 1:775 POLE LINE RD W STE 112
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5819
Practice Address - Country:US
Practice Address - Phone:208-814-8200
Practice Address - Fax:208-933-4921
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49699207R00000X
OH35.093591207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN126992000Medicaid
MNP00428375OtherMEDICARE RAILROAD
MNP00428375OtherMEDICARE RAILROAD