Provider Demographics
NPI:1861871857
Name:ROE, CRYSTAL GRACE (MD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:GRACE
Last Name:ROE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:CRYSTAL
Other - Middle Name:ROE
Other - Last Name:MONAGHEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:5423 OWENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75223
Mailing Address - Country:US
Mailing Address - Phone:817-964-0602
Mailing Address - Fax:
Practice Address - Street 1:601 CLARA BARTON BLVD STE 340
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75042-5755
Practice Address - Country:US
Practice Address - Phone:469-800-2279
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-22
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR4313207Q00000X
TXBP10054377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR4313OtherTEXAS MEDICAL BOARD
TX593905OtherPHYSICIAN IN TRAINING PERMIT