Healthcare Provider Details

I. General information

NPI: 1932108123
Provider Name (Legal Business Name): WALLACE VERNON CRANDALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2005
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDREN'S DRIVE
COLUMBUS OH
43205-2664
US

IV. Provider business mailing address

700 CHILDREN'S DRIVE
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-3450
  • Fax: 614-722-3454
Mailing address:
  • Phone: 614-722-3450
  • Fax: 614-722-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number35-078095
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: