Provider Demographics
NPI:1720029614
Name:LENZ, CRAIG JEROME (DO)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:JEROME
Last Name:LENZ
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:265 VOLUNTEER LN
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-7409
Mailing Address - Country:US
Mailing Address - Phone:423-489-9725
Mailing Address - Fax:423-869-7078
Practice Address - Street 1:1519 MAIN ST
Practice Address - Street 2:
Practice Address - City:SNEEDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37869-3657
Practice Address - Country:US
Practice Address - Phone:423-733-5030
Practice Address - Fax:423-733-5092
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7654207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX76540Medicaid
CAW20A7654Medicare ID - Type Unspecified
CA00AX76540Medicaid