1164428447 NPI number — DR. KEVIN DANIEL CRISMOND D.O.

Table of content: DR. KEVIN DANIEL CRISMOND D.O. (NPI 1164428447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164428447 NPI number — DR. KEVIN DANIEL CRISMOND D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISMOND
Provider First Name:
KEVIN
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164428447
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8773 PERIMETER PARK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32216-1165
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-493-3390
Provider Business Mailing Address Fax Number:
904-493-3395

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8773 PERIMETER PARK CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32216-1165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-493-3390
Provider Business Practice Location Address Fax Number:
904-493-3395
Provider Enumeration Date:
06/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS7896 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: OS7896 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 003174436A . This is a "GEORGIA MEDICAID" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: 152348 . This is a "WELLCARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2610299-00 . This is a "MEDICAID - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 47222 . This is a "FLORIDA BLUE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 45681 . This is a "MEDICARE - GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 264319 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 110220060 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: E2746Y . This is a "MEDICARE - INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2568802-00 . This is a "MEDICAID - INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 256880200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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