Provider Demographics
NPI:1689859274
Name:MARK E. CRISPIN, M.D., P.C.
Entity Type:Organization
Organization Name:MARK E. CRISPIN, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ELLISTON
Authorized Official - Last Name:CRISPIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-257-0064
Mailing Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1731
Mailing Address - Country:US
Mailing Address - Phone:404-257-9888
Mailing Address - Fax:404-257-1568
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD NE
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1731
Practice Address - Country:US
Practice Address - Phone:404-257-0064
Practice Address - Fax:404-257-1568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-02
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA032163208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA24CBVBMedicare UPIN