Provider Demographics
NPI:1093294662
Name:CRISCIO, EVAN MICHAEL (OD)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:MICHAEL
Last Name:CRISCIO
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2568 S RIDGEWOOD AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-7535
Mailing Address - Country:US
Mailing Address - Phone:386-424-1422
Mailing Address - Fax:386-424-1401
Practice Address - Street 1:2568 S RIDGEWOOD AVE STE 4
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:FL
Practice Address - Zip Code:32141
Practice Address - Country:US
Practice Address - Phone:386-424-1422
Practice Address - Fax:386-424-1401
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-14
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5583152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty