Provider Demographics
NPI:1669479689
Name:CRIDER, JAMES T (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:T
Last Name:CRIDER
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 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-636-6900
Mailing Address - Fax:360-636-2336
Practice Address - Street 1:812 OCEAN BEACH HWY
Practice Address - Street 2:STE. 200
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-4082
Practice Address - Country:US
Practice Address - Phone:360-636-6900
Practice Address - Fax:360-636-2336
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00035704207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
080128574OtherRR MEDICARE
OR150947Medicaid
WA8220782Medicaid
WA118361OtherLABOR & IND.
WA8921236OtherCRIME VICTIMS
080128574OtherRR MEDICARE
OR150947Medicaid