Provider Demographics
NPI:1669440269
Name:CRANDALL, BRIAN G (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:G
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-507-3513
Mailing Address - Fax:
Practice Address - Street 1:1300 N 500 E
Practice Address - Street 2:STE 320
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2408
Practice Address - Country:US
Practice Address - Phone:801-507-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT175425-1205207RC0001X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002087306Medicaid
ID003633800Medicaid
WY108869600Medicaid
060016799OtherRR MEDICARE
UT08641Medicaid
ID003633800Medicaid
UTD87681Medicare UPIN
WY108869600Medicaid