Healthcare Provider Details

I. General information

NPI: 1093709057
Provider Name (Legal Business Name): JOHN MARTIN CROWE JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 10/25/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1670 FENPARK DR
FENTON MO
63026-2918
US

IV. Provider business mailing address

1670 FENPARK DR
FENTON MO
63026-2918
US

V. Phone/Fax

Practice location:
  • Phone: 636-492-6376
  • Fax: 636-326-6557
Mailing address:
  • Phone: 636-492-6376
  • Fax: 636-326-6557

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2023012237
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35234
License Number StateIA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036118309
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: