=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558704908
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG A TORK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2013
-----------------------------------------------------
Last Update Date | 09/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 JARRETT WHITE RD
-----------------------------------------------------
City | TRIPLER ARMY MEDICAL CENTER
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96859-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-433-2971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7974 UW HEALTH CT
-----------------------------------------------------
City | MIDDLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53562-5531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | S7571
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 0101256568
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085N0700X
-----------------------------------------------------
Taxonomy Name | Neuroradiology Physician
-----------------------------------------------------
License Number | 77065
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------