Provider Demographics
NPI:1679761498
Name:CRANDALL, SUZANNE CATHERINE (DO)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:CATHERINE
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MORRIS ST STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1853
Mailing Address - Country:US
Mailing Address - Phone:304-388-6441
Mailing Address - Fax:304-388-6445
Practice Address - Street 1:415 MORRIS ST STE 300
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1853
Practice Address - Country:US
Practice Address - Phone:304-388-6441
Practice Address - Fax:304-388-6445
Is Sole Proprietor?:No
Enumeration Date:2007-10-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20090076532084N0400X
MI51010165552084N0400X
WV36792084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSKA2314004Medicare PIN
MOMA3554005Medicare PIN