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NPI Code Detail

MEDICARE: DR. TERRY LEE CROASDALE M.D.

MEDICARE: DR. TERRY LEE CROASDALE M.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
1207R00000XInternal Medicine PhysicianC43012CA

General Provider Information

NPI Number : 1295713147
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. TERRY LEE CROASDALE M.D.
Provider Business Mailing Address
First Line : 1262 E NORTH ST
Second Line :
City : MANTECA
State : CA
Zip : 95336-4962
Country : US
Telephone Number : 209-823-7646
Fax Number : 209-239-9594
Provider Business Practice Location Address
First Line : 1262 E NORTH ST
Second Line :
City : MANTECA
State : CA
Zip : 95336-4962
Country : US
Telephone Number : 209-823-7646
Fax Number : 209-239-9594
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/01/2006
Last Update Date : 04/09/2010

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