Provider Demographics
NPI:1790700573
Name:CARLOS, CRISOSTOMO J (MD)
Entity Type:Individual
Prefix:
First Name:CRISOSTOMO
Middle Name:J
Last Name:CARLOS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:801 MACARTHUR BLVD
Mailing Address - Street 2:SUITE 305
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2915
Mailing Address - Country:US
Mailing Address - Phone:219-703-2401
Mailing Address - Fax:219-703-6687
Practice Address - Street 1:801 MACARTHUR BLVD
Practice Address - Street 2:SUITE 305
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2915
Practice Address - Country:US
Practice Address - Phone:219-703-2401
Practice Address - Fax:219-703-6687
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2017-01-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN01026571A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100349730Medicaid
D69599Medicare UPIN
IN875160AMedicare ID - Type Unspecified