Provider Demographics
NPI:1750510236
Name:CRANDLEY, EDWIN FULGHUM (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:FULGHUM
Last Name:CRANDLEY
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 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-388-3483
Mailing Address - Fax:757-627-0334
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-3483
Practice Address - Fax:757-627-0334
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012554292085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1750510236OtherVIRGINIA PREMIER HEALTH PLAN
VAPAROtherUSA MANAGED CARE
VA1750510236OtherTRICARE
VA1750510236OtherCIGNA
VAPAROtherVIRGINIA HEALTH NETWORK
VAPAROtherCORVEL
VAPAROtherAETNA
VA10125900OtherOPTIMA HEALTH
VAPAROtherMULTIPLAN
VA1750510236Medicaid
NC1750510236Medicaid
VA1750510236OtherCOVENTRY NETWORK
VA1750510236OtherUNITED HEALTHCARE
VA10125900OtherOPTIMA HEALTH
VAVVD628AMedicare PIN