Healthcare Provider Details

I. General information

NPI: 1629728399
Provider Name (Legal Business Name): KEITH ALLEN CRENSHAW DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1147 E GRAND AVE
ESCONDIDO CA
92025-3219
US

IV. Provider business mailing address

PO BOX 843270
LOS ANGELES CA
90084-3270
US

V. Phone/Fax

Practice location:
  • Phone: 760-738-1583
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE6217
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD-001141
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: