Provider Demographics
NPI:1851568117
Name:CRISWELL, BRADEN JUSTIN (MD)
Entity Type:Individual
Prefix:
First Name:BRADEN
Middle Name:JUSTIN
Last Name:CRISWELL
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 1:2627 E WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-1412
Mailing Address - Country:US
Mailing Address - Phone:626-797-2002
Mailing Address - Fax:
Practice Address - Street 1:2627 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-1412
Practice Address - Country:US
Practice Address - Phone:626-797-2002
Practice Address - Fax:626-798-0567
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-14
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA123715207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery