Provider Demographics
NPI:1962453795
Name:ABBOTT, CRAIG LEON (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:LEON
Last Name:ABBOTT
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 1:801 YORK ST
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54220-4630
Mailing Address - Country:US
Mailing Address - Phone:920-663-9008
Mailing Address - Fax:920-684-1439
Practice Address - Street 1:3500 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-2413
Practice Address - Country:US
Practice Address - Phone:405-632-5565
Practice Address - Fax:405-632-3538
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17800207N00000X, 207ND0101X, 207NS0135X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100746010AMedicaid
OK541511960-003OtherBLUE CROSS BLUE SHIELD