Provider Demographics
NPI:1144320201
Name:DUDA, CRYSTAL ANNE (PT)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:ANNE
Last Name:DUDA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:
Other - Last Name:WATERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:315-295-2125
Practice Address - Street 1:4205 LONG BRANCH RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3213
Practice Address - Country:US
Practice Address - Phone:315-214-3431
Practice Address - Fax:315-546-2133
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020377225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02715644Medicaid
NYQ58794Medicare UPIN
NY02715644Medicaid