Healthcare Provider Details

I. General information

NPI: 1134340151
Provider Name (Legal Business Name): LAURA JANE CRANDALL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 01/31/2025
Certification Date: 01/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21040 GREENFIELD RD
OAK PARK MI
48237-3025
US

IV. Provider business mailing address

7700 2ND AVE
DETROIT MI
48202-2477
US

V. Phone/Fax

Practice location:
  • Phone: 248-967-6500
  • Fax: 248-967-6528
Mailing address:
  • Phone: 313-202-8660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number297340
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number052170
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301088972
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: