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General NPI Number Information
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NPI Number | 1194911768
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Entity Type | Organization
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Legal Business Name | CRESTVIEW NEUROLOGY
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 535 S FERDON BLVD SUITE C
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City | CRESTVIEW
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State | FL
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Zip | 32536-4446
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Country | US
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Telephone | 850-423-4664
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Fax | 850-398-8824
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Provider Business Mailing Address
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Address Line | 535 S FERDON BLVD STE C
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City | CRESTVIEW
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State | FL
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Zip | 32536-4446
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Country | US
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Telephone | 850-423-4664
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Fax | 850-398-8824
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Authorized Official
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Title or Position | SOLE OWNER
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Name | SHIJUN PAN
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Credential |
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Telephone | 850-424-4664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084N0400X
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Taxonomy Name | Neurology Physician
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License Number |
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License Number State |
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