Provider Demographics
NPI:1013966043
Name:CROWHURST, BRIAN ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:ROBERT
Last Name:CROWHURST
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 1:815 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2224
Mailing Address - Country:US
Mailing Address - Phone:817-321-0937
Mailing Address - Fax:
Practice Address - Street 1:1750 NORTH HAMPTON ROAD
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115
Practice Address - Country:US
Practice Address - Phone:214-946-4397
Practice Address - Fax:214-946-4399
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL60202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX166024303Medicaid
TX166024302Medicaid
TX166024303Medicaid
TX8G7758Medicare PIN
TXP00237588Medicare PIN
TX166024302Medicaid