Provider Demographics
NPI:1053646760
Name:CRISELL, DODDY LEE (DC)
Entity Type:Individual
Prefix:
First Name:DODDY
Middle Name:LEE
Last Name:CRISELL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:13733-1212
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:109 N MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:BAINBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:13733-1212
Practice Address - Country:US
Practice Address - Phone:607-967-2000
Practice Address - Fax:607-967-2004
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-14
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70011797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
J300014094Medicare PIN