Provider Demographics
NPI:1699834408
Name:CRIOLLO, ROMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:CRIOLLO
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 1:1680 DUNN AVE UNIT 35-37
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-4782
Mailing Address - Country:US
Mailing Address - Phone:904-760-4904
Mailing Address - Fax:
Practice Address - Street 1:1680 DUNN AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-4782
Practice Address - Country:US
Practice Address - Phone:904-760-4904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-07
Last Update Date:2023-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38184208000000X
FLME137455208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101870300Medicaid
FL118398900Medicaid