Provider Demographics
NPI:1427027358
Name:CRYSTAL, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:CRYSTAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 JERICHO TPKE
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-4713
Mailing Address - Country:US
Mailing Address - Phone:516-620-9510
Mailing Address - Fax:516-620-9512
Practice Address - Street 1:1510 JERICHO TPKE
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-4713
Practice Address - Country:US
Practice Address - Phone:516-620-9510
Practice Address - Fax:516-620-9512
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2010-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1527212085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA96168Medicare UPIN