Provider Demographics
NPI:1912004862
Name:CRADDOCK, GREGORY JAMES (DO)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:JAMES
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 MARTHA CUSTIS DR
Mailing Address - Street 2:STE C-7
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-2000
Mailing Address - Country:US
Mailing Address - Phone:703-998-6760
Mailing Address - Fax:
Practice Address - Street 1:1225 MARTHA CUSTIS DR
Practice Address - Street 2:STE C-7
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-2000
Practice Address - Country:US
Practice Address - Phone:703-998-6760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102201175204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH43738Medicare UPIN