1720347867 NPI number — ABIGAIL CRISOSTOMO MD

Table of content: ABIGAIL CRISOSTOMO MD (NPI 1720347867)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720347867 NPI number — ABIGAIL CRISOSTOMO MD

Organization/Personal Information

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

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:
1720347867
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/20/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2580
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65801-2580
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-829-4620
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1605 MARTIN SPRINGS DR
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
ROLLA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65401-2931
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-458-6326
Provider Business Practice Location Address Fax Number:
573-458-6763
Provider Enumeration Date:
05/10/2012

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: 207Q00000X , with the licence number:  2012003234 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P01089883 . This is a "RR MCR" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 431560263 . This is a "TRICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 1720347867 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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