Basic Information
| Provider Information | |||||||||
| NPI: | 1689650673 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRANE | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | GORDON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 940 EAST FIFTH STREET EAST WING | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5418241199 | ||||||||
| Practice Location | |||||||||
| Address1: | 913 11TH ST SE STE 1 | ||||||||
| Address2: | |||||||||
| City: | BANDON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974119168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413290144 | ||||||||
| FaxNumber: | 5413290143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2005 | ||||||||
| LastUpdateDate: | 11/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 11/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD22263 | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0577260001 | 01 | OR | DMERC NUMBER | OTHER | R0000WFBTV | 01 | OR | GROUP PIN NUMBER | OTHER | 110199508 | 01 | OR | RR MEDICARE PTAN NUMBER | OTHER | CD8723 | 01 | OR | RR MEDICARE GROUP NUMBER | OTHER | 288488 | 05 | OR | MEDICAID |