Healthcare Provider Details

I. General information

NPI: 1417213455
Provider Name (Legal Business Name): CRYSTAL MCLEOD D.O
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 N LOOP 288 STE 200
DENTON TX
76209-4958
US

IV. Provider business mailing address

1401 S BUCKNER BLVD SUITE 139
DALLAS TX
75217-1704
US

V. Phone/Fax

Practice location:
  • Phone: 940-381-1501
  • Fax: 940-591-7830
Mailing address:
  • Phone: 469-488-4400
  • Fax: 469-488-4401

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 TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP7310
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: