Provider Demographics
NPI:1932129111
Name:CRISWELL, MICHAEL DAVID (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DAVID
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:652 COLEMAN BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464
Mailing Address - Country:US
Mailing Address - Phone:843-849-2717
Mailing Address - Fax:843-849-2718
Practice Address - Street 1:652 COLEMAN BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464
Practice Address - Country:US
Practice Address - Phone:843-849-2717
Practice Address - Fax:843-849-2718
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1418152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA14298531Medicare PIN
SCV09690Medicare UPIN