Healthcare Provider Details

I. General information

NPI: 1013942903
Provider Name (Legal Business Name): CHAUNCEY WARREN CRANDALL IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 UNIVERSITY BLVD SUITE-200
JUPITER FL
33458
US

IV. Provider business mailing address

600 UNIVERSITY BLVD SUITE-200
JUPITER FL
33458
US

V. Phone/Fax

Practice location:
  • Phone: 561-627-2210
  • Fax: 561-627-5850
Mailing address:
  • Phone: 561-627-2210
  • Fax: 561-627-5850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME64798
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME64798
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: