Healthcare Provider Details

I. General information

NPI: 1174556484
Provider Name (Legal Business Name): CARLOS CRUDUP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

IV. Provider business mailing address

19310 S HALSTED ST
GLENWOOD IL
60425-1562
US

V. Phone/Fax

Practice location:
  • Phone: 708-300-3132
  • Fax: 708-300-3149
Mailing address:
  • Phone: 708-300-3132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-112800
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: