Provider Demographics
NPI:1174139554
Name:CRESTCARE FAMILY MEDICINE,PLLC
Entity type:Organization
Organization Name:CRESTCARE FAMILY MEDICINE,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GAURANGI
Authorized Official - Middle Name:M
Authorized Official - Last Name:ANKLESARIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-251-9698
Mailing Address - Street 1:817 S ELM PL STE 104
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5369
Mailing Address - Country:US
Mailing Address - Phone:918-251-9698
Mailing Address - Fax:405-241-9022
Practice Address - Street 1:817 S ELM PL STE 104
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5369
Practice Address - Country:US
Practice Address - Phone:918-251-9698
Practice Address - Fax:405-241-9022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty