Healthcare Provider Details

I. General information

NPI: 1578754792
Provider Name (Legal Business Name): JOHN CICERO CRAWFORD II P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3941 JOHN HOPKINS CT
DECATUR GA
30034-5709
US

IV. Provider business mailing address

80 JESSE HILL JR DR SE GRADY MEMORIAL HOSPITAL
ATLANTA GA
30303
US

V. Phone/Fax

Practice location:
  • Phone: 770-808-6054
  • Fax: 404-616-1973
Mailing address:
  • Phone: 404-616-6867
  • Fax: 404-616-1973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number001539
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: