Healthcare Provider Details

I. General information

NPI: 1174767867
Provider Name (Legal Business Name): CHAD MICHAEL CRAIG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2009
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11738 MAYFIELD AVE APT 112
LOS ANGELES CA
90049-5786
US

IV. Provider business mailing address

11738 MAYFIELD AVE APT 112
LOS ANGELES CA
90049-5786
US

V. Phone/Fax

Practice location:
  • Phone: 617-216-8811
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME158229
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number257925
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number74256-20
License Number StateWI
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA104175
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: