Provider Demographics
NPI:1528095395
Name:CRAWFORD, BRENDA M (MD)
Entity type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:M
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BRENDA
Other - Middle Name:KRISTINE
Other - Last Name:MICKELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-0430
Mailing Address - Country:US
Mailing Address - Phone:866-898-7136
Mailing Address - Fax:616-975-9827
Practice Address - Street 1:170 NORTH 1100 EAST
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003
Practice Address - Country:US
Practice Address - Phone:801-714-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6132263207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A767610Medicaid
UTD7012Medicaid
UT107046937101OtherSELECT HEALTH
UT870636000BCROtherEDUCATORS MUTUAL
UT61322631200001OtherBCBS
UT987965OtherDESERET MUTUAL
UT987965OtherDESERET MUTUAL
UTD7012Medicaid
000060884Medicare PIN