Healthcare Provider Details

I. General information

NPI: 1073581724
Provider Name (Legal Business Name): ANDREW J. CROAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6005 MONCLOVA RD STE 320
MAUMEE OH
43537-1862
US

IV. Provider business mailing address

6005 MONCLOVA RD STE 320
MAUMEE OH
43537-1862
US

V. Phone/Fax

Practice location:
  • Phone: 419-893-7134
  • Fax: 419-893-6942
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VF0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Obstetrics & Gynecology) Physician
License NumberOH6943C
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number34006843
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number34006843
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: