Basic Information
| Provider Information | |||||||||
| NPI: | 1275741464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRUDUP | ||||||||
| FirstName: | TRAVIS | ||||||||
| MiddleName: | WOLFE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8179240177 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761043906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8179272329 | ||||||||
| FaxNumber: | 8179240177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2007 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | M6089 | TX | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 186315101 | 05 | TX | MEDICAID | P00440259 | 01 | TX | RAIL ROAD MEDICARE | OTHER |