Provider Demographics
NPI:1376627745
Name:CRISOSTOMO, ANTONIO M (MD)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:M
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 S STATE STREET
Mailing Address - Street 2:REVENUE #200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604
Mailing Address - Country:US
Mailing Address - Phone:312-747-9443
Mailing Address - Fax:312-747-9447
Practice Address - Street 1:333 S STATE STREET
Practice Address - Street 2:REVENUE #200
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604
Practice Address - Country:US
Practice Address - Phone:312-747-9442
Practice Address - Fax:312-747-9447
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206543Medicare ID - Type Unspecified
E64633Medicare UPIN