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General NPI Number Information
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NPI Number | 1861871857
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Entity Type | Individual
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Provider Name | CRYSTAL GRACE ROE MD
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Gender | Female
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Dates
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Enumeration Date | 05/22/2015
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Last Update Date | 10/11/2017
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Provider Practice Location Address
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Address Line | 601 CLARA BARTON BLVD STE 340
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City | GARLAND
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State | TX
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Zip | 75042-5755
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Country | US
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Telephone | 469-800-2279
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Fax |
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Provider Business Mailing Address
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Address Line | 5423 OWENWOOD AVE
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City | DALLAS
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State | TX
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Zip | 75223
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Country | US
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Telephone | 817-964-0602
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | R4313
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | BP10054377
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License Number State | TX
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