Provider Demographics
NPI:1891985172
Name:CRISOSTOMO, CHRISTEN (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTEN
Middle Name:
Last Name:CRISOSTOMO
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 1:3241 WESTERN BRANCH BLVD
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-5260
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:2401 GODWIN BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8178
Practice Address - Country:US
Practice Address - Phone:757-923-9660
Practice Address - Fax:757-923-9665
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116016238207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1891985172Medicaid
015298B28Medicare PIN