Provider Demographics
NPI:1851442537
Name:EMILY CRANDALL, M.D
Entity Type:Organization
Organization Name:EMILY CRANDALL, M.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:CRANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-453-3452
Mailing Address - Street 1:1807 WILSHIRE BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5652
Mailing Address - Country:US
Mailing Address - Phone:310-453-3452
Mailing Address - Fax:310-453-2563
Practice Address - Street 1:1807 WILSHIRE BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5652
Practice Address - Country:US
Practice Address - Phone:310-453-3452
Practice Address - Fax:310-453-2563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG43175207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G431750Medicaid
CA00G431750Medicaid