Provider Demographics
NPI:1174502207
Name:CRISP, VERNON WESLEY JR (DO)
Entity Type:Individual
Prefix:
First Name:VERNON
Middle Name:WESLEY
Last Name:CRISP
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:PO BOX 52817
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85072-2817
Mailing Address - Country:US
Mailing Address - Phone:480-763-5808
Mailing Address - Fax:480-759-0647
Practice Address - Street 1:4530 E MUIRWOOD DR
Practice Address - Street 2:SUITE 110
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-7639
Practice Address - Country:US
Practice Address - Phone:480-763-5808
Practice Address - Fax:480-759-0647
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47184208100000X
AZ4375208100000X
FLOS 9787208100000X
GA05395208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN348620600Medicaid
MN250000638Medicare ID - Type Unspecified
I13719Medicare UPIN