Basic Information
| Provider Information | |||||||||
| NPI: | 1760779573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAWFORD | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | VENEGONIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAWFORD | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | VENEGONIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DPM | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1600 E GUDE DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208501341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3019337133 | ||||||||
| FaxNumber: | 3019337137 | ||||||||
| Practice Location | |||||||||
| Address1: | 6841 BLANDING BLVD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322444418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048622175 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2011 | ||||||||
| LastUpdateDate: | 03/01/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 01534 | MD | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | PO4012 | FL | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2353105 00 | 05 | MD | MEDICAID |