Provider Demographics
NPI:1649234618
Name:CRYSTAL, CHAD (MD)
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:CRYSTAL
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 1:2520 NW BIRKENDENE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-8573
Mailing Address - Country:US
Mailing Address - Phone:503-841-5765
Mailing Address - Fax:
Practice Address - Street 1:2900 S LOOP 256
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-6958
Practice Address - Country:US
Practice Address - Phone:903-731-1144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7699207PE0004X
ORMD27259207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164715803Medicaid
TX164715805Medicaid
TX8B8898Medicare ID - Type Unspecified
TX164715805Medicaid
TX8D8672Medicare ID - Type Unspecified
ORI02500Medicare UPIN
TXI02500Medicare UPIN