Provider Demographics
NPI:1700866290
Name:CRUTCHFIELD, JAY M (MD FACS)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:M
Last Name:CRUTCHFIELD
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 E CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-8046
Mailing Address - Country:US
Mailing Address - Phone:208-795-4382
Mailing Address - Fax:
Practice Address - Street 1:1401 E CENTRAL DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-8046
Practice Address - Country:US
Practice Address - Phone:208-795-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21253208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ020041119OtherRAILROAD MEDICARE
AZ339756Medicaid
AZ339756Medicaid