Provider Demographics
NPI:1275709545
Name:DEWEESE, CRYSTAL L (MD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:L
Last Name:DEWEESE
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 1:515 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-8975
Mailing Address - Country:US
Mailing Address - Phone:479-717-7626
Mailing Address - Fax:471-717-7327
Practice Address - Street 1:515 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-8975
Practice Address - Country:US
Practice Address - Phone:479-717-7626
Practice Address - Fax:471-717-7327
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-73952084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry