Provider Demographics
NPI:1174672869
Name:CRICKELLAS, PETER (DPM)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:CRICKELLAS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 LYONS PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07081-1604
Mailing Address - Country:US
Mailing Address - Phone:973-912-8095
Mailing Address - Fax:973-912-8095
Practice Address - Street 1:24 LYONS PL
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1604
Practice Address - Country:US
Practice Address - Phone:973-912-8095
Practice Address - Fax:973-912-8095
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00919782Medicaid
NJT45449Medicare UPIN
NJCR455121Medicare ID - Type Unspecified