Provider Demographics
NPI:1619947033
Name:CRISWELL, MARK A (MD, FACS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 BOATNER RD STE 114
Mailing Address - Street 2:
Mailing Address - City:EGLIN AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32542-1302
Mailing Address - Country:US
Mailing Address - Phone:850-883-8264
Mailing Address - Fax:
Practice Address - Street 1:307 BOATNER RD STE 114
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542
Practice Address - Country:US
Practice Address - Phone:850-883-8264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046367A207Y00000X, 207YS0012X
CO0056111207YX0007X
CO00056111207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO21400253Medicaid
CO027034OtherKAISER COMMERCIAL NUMBER
CO502728YK5YMedicare PIN