Provider Demographics
NPI:1710957139
Name:CROUCH, JOHN RAYMOND JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RAYMOND
Last Name:CROUCH
Suffix:JR
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 1:1441 E 75TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-7345
Mailing Address - Country:US
Mailing Address - Phone:918-710-4200
Mailing Address - Fax:918-293-3155
Practice Address - Street 1:1441 E 75TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-7345
Practice Address - Country:US
Practice Address - Phone:918-710-4200
Practice Address - Fax:918-293-3155
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK11771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100054170BMedicaid
OK100054170BMedicaid