Provider Demographics
NPI:1225036528
Name:CRISCENZO, DONNA R (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:R
Last Name:CRISCENZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 GOOSE LANE
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-2115
Mailing Address - Country:US
Mailing Address - Phone:203-458-2888
Mailing Address - Fax:203-458-2889
Practice Address - Street 1:199 GOOSE LANE
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-2115
Practice Address - Country:US
Practice Address - Phone:203-458-2888
Practice Address - Fax:203-458-2889
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022662207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
110001392Medicare ID - Type Unspecified
B83447Medicare UPIN