MEDICARE: KENNETH GRAHAM CRUTCHFIELD O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	T02684	MO
2	152W00000X	Optometrist	0601001489	VA
3	152W00000X	Optometrist	04962T	TX

General Provider Information

NPI Number	:	1093916223
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH GRAHAM CRUTCHFIELD O.D.

Provider Business Mailing Address
First Line	:	310 KENT ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-6107
Country	:	US
Telephone Number	:	573-659-7363
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 KENT ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109-6107
Country	:	US
Telephone Number	:	573-659-7363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2007
Last Update Date	:	07/08/2007

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