Provider Demographics
NPI:1821106295
Name:CRISOLOGO, GUILLERMO V (MD)
Entity Type:Individual
Prefix:DR
First Name:GUILLERMO
Middle Name:V
Last Name:CRISOLOGO
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 1:620 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-2413
Mailing Address - Country:US
Mailing Address - Phone:419-734-3116
Mailing Address - Fax:419-734-5786
Practice Address - Street 1:620 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2413
Practice Address - Country:US
Practice Address - Phone:419-734-3116
Practice Address - Fax:419-734-5786
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-032803208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH25500OtherANTHEM BCBS OF OHIO
OH0157397Medicaid
OH0157397Medicaid
OHCR0152741Medicare ID - Type Unspecified