Provider Demographics
NPI:1790070902
Name:CRAWFORD, JIM
Entity Type:Individual
Prefix:
First Name:JIM
Middle Name:
Last Name:CRAWFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34277 TRAMPINI CMN
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-1844
Mailing Address - Country:US
Mailing Address - Phone:510-881-3100
Mailing Address - Fax:
Practice Address - Street 1:34277 TRAMPINI CMN
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94555-1844
Practice Address - Country:US
Practice Address - Phone:510-881-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC5305185172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver