Healthcare Provider Details

I. General information

NPI: 1225230915
Provider Name (Legal Business Name): CRYSTAL POURCIAU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 N DUNLAP ST FL 4
MEMPHIS TN
38105-4625
US

IV. Provider business mailing address

49 N DUNLAP ST FL 3
MEMPHIS TN
38103-2802
US

V. Phone/Fax

Practice location:
  • Phone: 901-287-7337
  • Fax: 901-287-5506
Mailing address:
  • Phone: 901-287-4825
  • Fax: 901-287-4820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License NumberN9400
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number56555
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: