Provider Demographics
NPI:1164428447
Name:CRISMOND, KEVIN DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:DANIEL
Last Name:CRISMOND
Suffix:
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 1:8773 PERIMETER PARK CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-1165
Mailing Address - Country:US
Mailing Address - Phone:904-493-3390
Mailing Address - Fax:904-493-3395
Practice Address - Street 1:8773 PERIMETER PARK CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1165
Practice Address - Country:US
Practice Address - Phone:904-493-3390
Practice Address - Fax:904-493-3395
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS7896207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003174436AOtherGEORGIA MEDICAID
FL152348OtherWELLCARE
FL2610299-00OtherMEDICAID - GROUP
FL47222OtherFLORIDA BLUE
FL45681OtherMEDICARE - GROUP
FL264319OtherAVMED
FL110220060OtherRR MEDICARE
FLE2746YOtherMEDICARE - INDIVIDUAL
FL2568802-00OtherMEDICAID - INDIVIDUAL
FLE2746YOtherMEDICARE - INDIVIDUAL