Healthcare Provider Details

I. General information

NPI: 1629044870
Provider Name (Legal Business Name): VINCENT G CRUMP DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 BRANDON TRACE AVE
BRANDON FL
33510-2027
US

IV. Provider business mailing address

1735 BRANDON TRACE AVE
BRANDON FL
33510-2027
US

V. Phone/Fax

Practice location:
  • Phone: 813-416-0207
  • Fax: 813-881-9118
Mailing address:
  • Phone: 813-416-0207
  • Fax: 813-881-9118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO2083
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: