Healthcare Provider Details

I. General information

NPI: 1982998225
Provider Name (Legal Business Name): CHANCE NOLAN CRUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2011
Last Update Date: 06/21/2021
Certification Date: 06/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SL YOUNG BLVD
OKLAHOMA CITY OK
73104-5036
US

IV. Provider business mailing address

PO BOX 518
ARDMORE OK
73402-0518
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5635
  • Fax:
Mailing address:
  • Phone: 479-452-9416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number28615
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: