Healthcare Provider Details

I. General information

NPI: 1013159177
Provider Name (Legal Business Name): CRYSTAL MILLER PROUD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2009
Last Update Date: 10/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 SOUTHAMPTON AVE
NORFOLK VA
23510-1021
US

IV. Provider business mailing address

850 SOUTHAMPTON AVE
NORFOLK VA
23510-1021
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-9920
  • Fax: 757-668-9930
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberA117087
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number0101258310
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number0101258310
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: