Provider Demographics
NPI:1881633568
Name:CRESPO, JORGE LUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:JORGE
Middle Name:LUIS
Last Name:CRESPO
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:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01302-0910
Mailing Address - Country:US
Mailing Address - Phone:413-772-8500
Mailing Address - Fax:413-772-8900
Practice Address - Street 1:745A ROUTE 63
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:NH
Practice Address - Zip Code:03443-3604
Practice Address - Country:US
Practice Address - Phone:800-303-8984
Practice Address - Fax:603-363-4450
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8345207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT8233OtherBC/BS VT
NH0104793Y0VT01OtherBC/BS NH
NH30003577Medicaid
VTOVN2029Medicaid
NH0104793Y0VT01OtherBC/BS NH
E45953Medicare UPIN