Provider Demographics
NPI:1871689349
Name:CRAWFORD, ROBERTA J (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTA
Middle Name:J
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S TRUMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63019
Mailing Address - Country:US
Mailing Address - Phone:636-933-6020
Mailing Address - Fax:636-933-6420
Practice Address - Street 1:400 S TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1726
Practice Address - Country:US
Practice Address - Phone:636-933-6020
Practice Address - Fax:636-933-6420
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3244152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO314639113Medicaid
MO010791336Medicare ID - Type Unspecified
MO314639113Medicaid
1083869614Medicare NSC
5114780001Medicare NSC