Provider Demographics
NPI:1255349098
Name:CRANDELL, JASON MALCOLM (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:MALCOLM
Last Name:CRANDELL
Suffix:
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:PO BOX 1741
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-1741
Mailing Address - Country:US
Mailing Address - Phone:336-778-0506
Mailing Address - Fax:336-778-0570
Practice Address - Street 1:2511 NEUDORF RD STE D
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8922
Practice Address - Country:US
Practice Address - Phone:336-778-0506
Practice Address - Fax:336-778-0570
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC23500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC73006OtherMEDCOST
NC8925220Medicaid
NCMR109OtherBLUE CROSS EMPIRE
NC05667001OtherMAGELLAN
NC1504998OtherUNITED HEALTH CARE
NCMR109OtherBLUE CROSS EMPIRE
NCC18215Medicare UPIN