Basic Information
| Provider Information | |||||||||
| NPI: | 1649270539 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRAYTOR | ||||||||
| FirstName: | BRET | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775600 | ||||||||
| FaxNumber: | 6153735280 | ||||||||
| Practice Location | |||||||||
| Address1: | 2600 SAINT MICHAEL DR | ||||||||
| Address2: | |||||||||
| City: | TEXARKANA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755035220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036145111 | ||||||||
| FaxNumber: | 9036145114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2005 | ||||||||
| LastUpdateDate: | 05/20/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RP1001X | J8974 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | E0731 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RP1001X | 16975 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
| ID | Type | State | Issuer | Description | 130592001 | 05 | AR | MEDICAID | 10090430C | 05 | OK | MEDICAID | 100706402 | 05 | TX | MEDICAID |