Healthcare Provider Details

I. General information

NPI: 1376961888
Provider Name (Legal Business Name): JIMMY CRUMBACHER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 45011
APO AP
96343-5011
US

IV. Provider business mailing address

UNIT 45011
APO AP
96343-5011
US

V. Phone/Fax

Practice location:
  • Phone: 315-263-4128
  • Fax:
Mailing address:
  • Phone: 315-263-4128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD2016-0515
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: