Healthcare Provider Details

I. General information

NPI: 1881121655
Provider Name (Legal Business Name): CRYSTAL KUCUK MACOMB DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 N CEDAR CREST BLVD
ALLENTOWN PA
18104-2304
US

IV. Provider business mailing address

2100 MACK BLVD FL 4
ALLENTOWN PA
18103-5622
US

V. Phone/Fax

Practice location:
  • Phone: 610-402-8900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102206099
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4621
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License NumberOS025775
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: