Provider Demographics
NPI:1003853722
Name:DIMAFELIX, CRISANTO G (MD)
Entity Type:Individual
Prefix:
First Name:CRISANTO
Middle Name:G
Last Name:DIMAFELIX
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1041 GRIMES DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15810 MIDWAY ROAD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001
Practice Address - Country:US
Practice Address - Phone:972-458-8111
Practice Address - Fax:972-458-7776
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM2606207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L22781Medicare UPIN
TXI48269Medicare UPIN
TX00Z957Medicare PIN