Healthcare Provider Details

I. General information

NPI: 1437390333
Provider Name (Legal Business Name): JOHN WENDELL CRAYTON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2009
Last Update Date: 07/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 FRANKLIN ST
MICHIGAN CITY IN
46360-6140
US

IV. Provider business mailing address

3926 NEW VISION DR
FORT WAYNE IN
46845-1712
US

V. Phone/Fax

Practice location:
  • Phone: 219-787-8104
  • Fax: 219-787-8104
Mailing address:
  • Phone: 260-266-8211
  • Fax: 260-458-5641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number01066287A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036048261
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: