Provider Demographics
NPI:1487632246
Name:CRISCUOLA, ROBERT J (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:J
Last Name:CRISCUOLA
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 1:3331 N VALDOSTA RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:229-247-2211
Mailing Address - Fax:229-247-9313
Practice Address - Street 1:3331 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602
Practice Address - Country:US
Practice Address - Phone:229-247-2211
Practice Address - Fax:229-247-9313
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053436208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H95456Medicare UPIN