Provider Demographics
NPI:1174556484
Name:CRUDUP, CARLOS (MD)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CRUDUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19310 S HALSTED ST
Mailing Address - Street 2:
Mailing Address - City:GLENWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60425-1562
Mailing Address - Country:US
Mailing Address - Phone:708-300-3132
Mailing Address - Fax:
Practice Address - Street 1:19310 S HALSTED ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IL
Practice Address - Zip Code:60425-1562
Practice Address - Country:US
Practice Address - Phone:708-300-3132
Practice Address - Fax:708-300-3149
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI25798Medicare UPIN
ILIL7621001Medicare Oscar/Certification