Provider Demographics
NPI:1104864891
Name:CRISAN, MIRELA
Entity Type:Individual
Prefix:
First Name:MIRELA
Middle Name:
Last Name:CRISAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MIRELA
Other - Middle Name:
Other - Last Name:CRISAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4063 FAIRFAX DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43220-4522
Mailing Address - Country:US
Mailing Address - Phone:614-256-6855
Mailing Address - Fax:
Practice Address - Street 1:1601 W BROAD ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1054
Practice Address - Country:US
Practice Address - Phone:614-205-4596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-3853-C207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4141292Medicare PIN