=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851498711
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT MARVIN CRAWFORD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/20/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22629 TWAIN HARTE DR
-----------------------------------------------------
City | TWAIN HARTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95383-9628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-586-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22629 TWAIN HARTE DR
-----------------------------------------------------
City | TWAIN HARTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95383-9628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-586-2772
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | CA 25500
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------