Provider Demographics
NPI:1144269176
Name:CRANDELL, COLLEEN MARY (DO)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARY
Last Name:CRANDELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 DEBORAH DR
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-5102
Mailing Address - Country:US
Mailing Address - Phone:607-729-0779
Mailing Address - Fax:
Practice Address - Street 1:200 PLAZA DR
Practice Address - Street 2:SUITE B
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-3680
Practice Address - Country:US
Practice Address - Phone:607-729-2777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227706207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2K9901Medicare ID - Type Unspecified