Provider Demographics
NPI:1013159177
Name:PROUD, CRYSTAL MILLER (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:MILLER
Last Name:PROUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 SOUTHAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:850 SOUTHAMPTON AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1021
Practice Address - Country:US
Practice Address - Phone:757-668-9920
Practice Address - Fax:757-668-9930
Is Sole Proprietor?:No
Enumeration Date:2009-04-03
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1170872084N0402X
VA01012583102084N0008X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0008XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeuromuscular Medicine