Provider Demographics
NPI:1821673062
Name:JEFFREY CRUDO MD CORP
Entity Type:Organization
Organization Name:JEFFREY CRUDO MD CORP
Other - Org Name:COAST MEDICAL AND BOTOX
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-715-6890
Mailing Address - Street 1:1100 S COAST HWY STE 206
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2972
Mailing Address - Country:US
Mailing Address - Phone:949-715-6890
Mailing Address - Fax:
Practice Address - Street 1:1100 S COAST HWY STE 206
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2972
Practice Address - Country:US
Practice Address - Phone:949-715-6890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-09
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty