Provider Demographics
NPI:1770564320
Name:CRUTCHFIELD, JOHN STUART (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:STUART
Last Name:CRUTCHFIELD
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 1:722 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2001
Mailing Address - Country:US
Mailing Address - Phone:903-531-9901
Mailing Address - Fax:903-531-9739
Practice Address - Street 1:722 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2001
Practice Address - Country:US
Practice Address - Phone:903-531-9901
Practice Address - Fax:903-531-9739
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6140207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX163049302Medicaid
TX0019KVOtherBLUE CROSS BLUE SHIELD
TX00892VMedicare ID - Type Unspecified
TXF79364Medicare UPIN