Provider Demographics
NPI:1619963121
Name:CRAWFORD, GARY STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:STEPHEN
Last Name:CRAWFORD
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 1:125 RIVER VINE PKWY
Mailing Address - Street 2:
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-2377
Mailing Address - Country:US
Mailing Address - Phone:910-285-2134
Mailing Address - Fax:910-285-4610
Practice Address - Street 1:112 MEDICAL VILLAGE DR
Practice Address - Street 2:UNIT D
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-1668
Practice Address - Country:US
Practice Address - Phone:910-285-7592
Practice Address - Fax:910-285-4610
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8925388Medicaid
NC8925388Medicaid
NC2209414BMedicare ID - Type Unspecified