Provider Demographics
NPI:1205472396
Name:CRADDOCK, TYRONE
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:
Last Name:CRADDOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-2962
Mailing Address - Country:US
Mailing Address - Phone:860-600-3132
Mailing Address - Fax:
Practice Address - Street 1:47 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-2962
Practice Address - Country:US
Practice Address - Phone:860-600-3132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-23
Last Update Date:2019-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL347C00000X172A00000X
CT347C00000X347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver