Provider Demographics
NPI:1043771306
Name:CRASTO, DAVID WALTON JR (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WALTON
Last Name:CRASTO
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4030 DOGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6607
Mailing Address - Country:US
Mailing Address - Phone:601-613-7424
Mailing Address - Fax:
Practice Address - Street 1:154 S COMPASS WAY
Practice Address - Street 2:
Practice Address - City:DANIA
Practice Address - State:FL
Practice Address - Zip Code:33004-2368
Practice Address - Country:US
Practice Address - Phone:954-807-9433
Practice Address - Fax:954-807-9725
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS17041207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17041OtherOSTEOPATHIC MEDICAL LICENSE