Provider Demographics
NPI:1043639453
Name:TANK, CRYSTAL (MD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:TANK
Suffix:
Gender:F
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:PO BOX 419430
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-9430
Mailing Address - Country:US
Mailing Address - Phone:201-967-8221
Mailing Address - Fax:201-483-2242
Practice Address - Street 1:311 BAY AVE
Practice Address - Street 2:MMG INTERNAL MED
Practice Address - City:GLEN RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07028
Practice Address - Country:US
Practice Address - Phone:973-748-9246
Practice Address - Fax:973-748-8755
Is Sole Proprietor?:No
Enumeration Date:2014-04-14
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA10421000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine