Provider Demographics
NPI:1750386215
Name:CROUCH, NATHAN A (OD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:A
Last Name:CROUCH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-1250
Mailing Address - Fax:
Practice Address - Street 1:3101 FIELDS SOUTH DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-3743
Practice Address - Country:US
Practice Address - Phone:217-366-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046009653152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05832113OtherBLUE CROSS
IL046009653Medicaid
IL05832113OtherBLUE CROSS
ILV01093Medicare UPIN
ILK49004Medicare PIN
ILP00454672Medicare Oscar/Certification