Healthcare Provider Details

I. General information

NPI: 1720048002
Provider Name (Legal Business Name): ALAN GREGORY CRAWFORD PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 11/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MARKS ROAD
OCEAN SPRINGS MS
39564
US

IV. Provider business mailing address

P O BOX 3488 DEPT 05-115
TUPELO MS
38803-3488
US

V. Phone/Fax

Practice location:
  • Phone: 228-872-8873
  • Fax: 228-872-8876
Mailing address:
  • Phone: 228-872-8873
  • Fax: 678-553-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberPA013
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00013
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: