1679533756 NPI number — RICARDO H CRISOSTOMO MD

Table of content: RICARDO H CRISOSTOMO MD (NPI 1679533756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679533756 NPI number — RICARDO H CRISOSTOMO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRISOSTOMO
Provider First Name:
RICARDO
Provider Middle Name:
H
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CRISOSTOMO
Provider Other First Name:
JOSE
Provider Other Middle Name:
RICARDO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679533756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MERCADO ST STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURANGO
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81301-7306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-385-7977
Provider Business Mailing Address Fax Number:
970-385-6727

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MERCARDO ST.
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
DURANGO
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81301-7306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-385-7977
Provider Business Practice Location Address Fax Number:
970-385-6727
Provider Enumeration Date:
03/24/2006

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: 207RH0003X , with the licence number:  DR.0067681 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0003X , with the licence number: ME89846 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 272461800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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