Healthcare Provider Details

I. General information

NPI: 1902367683
Provider Name (Legal Business Name): ASHLEY P CRADDOCK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 LEE ST
CHARLOTTESVILLE VA
22908-0816
US

IV. Provider business mailing address

PO BOX 749112
ATLANTA GA
30374-9112
US

V. Phone/Fax

Practice location:
  • Phone: 434-982-1018
  • Fax: 434-924-9492
Mailing address:
  • Phone: 434-295-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number0101277125
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number0101277125
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: