Healthcare Provider Details

I. General information

NPI: 1376632075
Provider Name (Legal Business Name): EARL RUSSELL CROUCH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4665 SOUTH BLVD
VIRGINIA BEACH VA
23452-1055
US

IV. Provider business mailing address

4665 SOUTH BLVD
VIRGINIA BEACH VA
23452-1055
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-0050
  • Fax: 757-461-4538
Mailing address:
  • Phone: 757-461-0050
  • Fax: 757-461-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101236715
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: