Provider Demographics
NPI:1255390472
Name:TATE, CRYSTAL LANE (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:LANE
Last Name:TATE
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:PO BOX 492
Mailing Address - Street 2:
Mailing Address - City:ECRU
Mailing Address - State:MS
Mailing Address - Zip Code:38841-0492
Mailing Address - Country:US
Mailing Address - Phone:662-489-5609
Mailing Address - Fax:662-489-3814
Practice Address - Street 1:375 MAIN ST
Practice Address - Street 2:
Practice Address - City:ECRU
Practice Address - State:MS
Practice Address - Zip Code:38841-9118
Practice Address - Country:US
Practice Address - Phone:662-489-5609
Practice Address - Fax:662-489-3814
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2008-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13565207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS080003363Medicare ID - Type Unspecified
MSF32182Medicare UPIN