Provider Demographics
NPI:1760463640
Name:CRANDALL, HEIDE KATHLEEN (MD)
Entity Type:Individual
Prefix:MS
First Name:HEIDE
Middle Name:KATHLEEN
Last Name:CRANDALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 MARTIN STREET
Mailing Address - Street 2:
Mailing Address - City:WELLSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14895
Mailing Address - Country:US
Mailing Address - Phone:585-593-9497
Mailing Address - Fax:585-596-4048
Practice Address - Street 1:46 MARTIN STREET
Practice Address - Street 2:
Practice Address - City:WELLSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14895
Practice Address - Country:US
Practice Address - Phone:585-593-9497
Practice Address - Fax:585-596-4048
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210775208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01872279Medicaid
NY00020353001OtherUNIVERA
NY000525220001OtherBCBS
NY000525220001OtherBCBS
G78803Medicare UPIN