Healthcare Provider Details

I. General information

NPI: 1326300187
Provider Name (Legal Business Name): CRYSTAL AJA BROGAN MEDICAL DOCTOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CRYSTAL AJA CRAIG MD

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 08/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 561
WYNNEWOOD PA
19096-3436
US

IV. Provider business mailing address

100 E LANCASTER AVE SUITE 561
WYNNEWOOD PA
19096
US

V. Phone/Fax

Practice location:
  • Phone: 610-642-7714
  • Fax: 610-649-0761
Mailing address:
  • Phone: 610-642-7714
  • Fax: 610-649-0761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMD458067
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: