Provider Demographics
NPI:1457404477
Name:CROWDER, CLINTON DWAYNE (MD)
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:DWAYNE
Last Name:CROWDER
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 1:1111 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2613
Mailing Address - Country:US
Mailing Address - Phone:515-247-3115
Mailing Address - Fax:
Practice Address - Street 1:1111 6TH AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2613
Practice Address - Country:US
Practice Address - Phone:515-247-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN18936207ZP0102X
MN50489207ZP0105X
IA39073207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN220001257Medicare PIN