Provider Demographics
NPI:1891753497
Name:LASTINE, CRAIG LELLAND (MD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:LELLAND
Last Name:LASTINE
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 308
Mailing Address - Street 2:
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81402-0308
Mailing Address - Country:US
Mailing Address - Phone:970-497-8416
Mailing Address - Fax:970-497-8410
Practice Address - Street 1:2021 N 12TH ST
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81501-2980
Practice Address - Country:US
Practice Address - Phone:970-242-0920
Practice Address - Fax:406-587-1343
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.00440102085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT152524Medicaid
CO06350003Medicaid
MT0152507Medicaid
MTG12885Medicare UPIN
MT000084790Medicare ID - Type Unspecified
CO06350003Medicaid
MT000085300Medicare ID - Type Unspecified