Healthcare Provider Details

I. General information

NPI: 1811290257
Provider Name (Legal Business Name): ROGER T CRENSHAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2010
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 PACIFIC HIGHWAY SUITE 2806
SAN DIEGO CA
92101-2580
US

IV. Provider business mailing address

1325 PACIFIC HIGHWAY SUITE 2806
SAN DIEGO CA
92101-2580
US

V. Phone/Fax

Practice location:
  • Phone: 619-564-8494
  • Fax: 619-564-8783
Mailing address:
  • Phone: 619-564-8494
  • Fax: 619-564-8783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberAFE24041
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberAFE24041
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: