Healthcare Provider Details

I. General information

NPI: 1285641886
Provider Name (Legal Business Name): OWEN JAMES MCCRUDDEN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 12/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8029 JERICHO TPKE
WOODBURY NY
11797
US

IV. Provider business mailing address

8029 JERICHO TPKE
WOODBURY NY
11797
US

V. Phone/Fax

Practice location:
  • Phone: 516-496-0900
  • Fax: 516-496-0901
Mailing address:
  • Phone: 516-496-0900
  • Fax: 516-496-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number005928-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: