Provider Demographics
NPI:1972793396
Name:CRISPEN, PAUL LUTHER (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:LUTHER
Last Name:CRISPEN
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 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-273-7537
Mailing Address - Fax:859-323-1944
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-273-7537
Practice Address - Fax:859-323-1944
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49958208800000X
KY42809208800000X
FLME115276208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008616900Medicaid
MN262123000Medicaid
MNP00632037OtherRAILROAD MEDICARE
MNP00632037OtherRAILROAD MEDICARE
FLHG602ZMedicare PIN