Provider Demographics
NPI:1942210497
Name:CRENSHAW, CHARLES N III (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:N
Last Name:CRENSHAW
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 AVALON CIR STE A
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7843
Mailing Address - Country:US
Mailing Address - Phone:601-992-6511
Mailing Address - Fax:601-992-5684
Practice Address - Street 1:216 AVALON CIR STE A
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:MS
Practice Address - Zip Code:39047-7843
Practice Address - Country:US
Practice Address - Phone:601-992-6511
Practice Address - Fax:601-992-5684
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2019-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSB30608Medicare UPIN