Healthcare Provider Details

I. General information

NPI: 1952477531
Provider Name (Legal Business Name): ANDREA CRACCHIOLO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 06/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 UCLA MEDICAL PLZ SUITE 140
LOS ANGELES CA
90095-8344
US

IV. Provider business mailing address

5767 W CENTURY BLVD SUITE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-1234
  • Fax:
Mailing address:
  • Phone: 310-319-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA21344
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberA21344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: