Provider Demographics
NPI:1295713147
Name:CROASDALE, TERRY LEE (MD)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:LEE
Last Name:CROASDALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1262 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4962
Mailing Address - Country:US
Mailing Address - Phone:209-823-7646
Mailing Address - Fax:209-239-9594
Practice Address - Street 1:1262 E NORTH ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4962
Practice Address - Country:US
Practice Address - Phone:209-823-7646
Practice Address - Fax:209-239-9594
Is Sole Proprietor?:No
Enumeration Date:2006-01-01
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC43012207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C430120Medicare PIN
CAF34134Medicare UPIN