Basic Information
| Provider Information | |||||||||
| NPI: | 1073763140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRADDOCK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110429 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800420429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3034937000 | ||||||||
| FaxNumber: | 3034937202 | ||||||||
| Practice Location | |||||||||
| Address1: | 13123 EAST 16TH AVENUE ; B115 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7207776892 | ||||||||
| FaxNumber: | 7207777289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N0711 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0207X | N0711 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology |
ID Information
| ID | Type | State | Issuer | Description | 82387273 | 05 | CO | MEDICAID |