Healthcare Provider Details

I. General information

NPI: 1497499198
Provider Name (Legal Business Name): MICHELLE DIANE CRODA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR
COLUMBIA MO
65201-5276
US

IV. Provider business mailing address

1 HOSPITAL DR
COLUMBIA MO
65201-5276
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-4141
  • Fax:
Mailing address:
  • Phone: 573-882-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMTL500002118
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: