Provider Demographics
NPI:1629855655
Name:CRAIG, BOBBY MARCUS
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:MARCUS
Last Name:CRAIG
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BOBBY
Other - Middle Name:MARCUS
Other - Last Name:CRAIG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4149 E 71ST ST APT 4
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44105-5082
Mailing Address - Country:US
Mailing Address - Phone:216-543-6259
Mailing Address - Fax:
Practice Address - Street 1:4149 E 71ST ST APT 4
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44105-5082
Practice Address - Country:US
Practice Address - Phone:216-543-6259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSX887399172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver