Provider Demographics
NPI:1396180477
Name:UDALL, CRAIG KENYON (DPM)
Entity type:Individual
Prefix:
First Name:CRAIG
Middle Name:KENYON
Last Name:UDALL
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14539 W INDIAN SCHOOL RD STE 880
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-9279
Mailing Address - Country:US
Mailing Address - Phone:623-248-4734
Mailing Address - Fax:623-259-7006
Practice Address - Street 1:14539 W INDIAN SCHOOL RD STE 880
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-9279
Practice Address - Country:US
Practice Address - Phone:623-248-4734
Practice Address - Fax:623-259-7006
Is Sole Proprietor?:No
Enumeration Date:2013-05-02
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0859213E00000X, 213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8154560001OtherMEDICARE DME
AZZ274188OtherMEDICARE PTAN
AZ270291Medicaid