MEDICARE: EARL RUSSELL CROUCH III MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	0101236715	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376632075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EARL RUSSELL CROUCH III MD

Provider Business Mailing Address
First Line	:	4665 SOUTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1055
Country	:	US
Telephone Number	:	757-461-0050
Fax Number	:	757-461-4538

Provider Business Practice Location Address
First Line	:	4665 SOUTH BLVD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23452-1055
Country	:	US
Telephone Number	:	757-461-0050
Fax Number	:	757-461-4538

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	10/17/2018

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