Provider Demographics
NPI:1134340151
Name:CRANDALL, LAURA JANE (MD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JANE
Last Name:CRANDALL
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 1:7700 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2477
Mailing Address - Country:US
Mailing Address - Phone:313-202-8660
Mailing Address - Fax:
Practice Address - Street 1:21040 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3025
Practice Address - Country:US
Practice Address - Phone:248-967-6500
Practice Address - Fax:248-967-6528
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY297340207Q00000X
CT052170207Q00000X
MI4301088972207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008045657Medicaid