Provider Demographics
NPI:1902802606
Name:CROWELL, THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:CROWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 GOODLETTE RD N
Mailing Address - Street 2:SUITE 500
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34102-5656
Mailing Address - Country:US
Mailing Address - Phone:239-260-3586
Mailing Address - Fax:239-254-3105
Practice Address - Street 1:720 GOODLETTE RD N
Practice Address - Street 2:SUITE 500
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34102-5656
Practice Address - Country:US
Practice Address - Phone:239-260-3586
Practice Address - Fax:239-254-3105
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0066982207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA08859Medicare UPIN