Provider Demographics
NPI:1255405882
Name:CRISMALI, NICHOLAS C (DPM)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:C
Last Name:CRISMALI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18151 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4907
Mailing Address - Country:US
Mailing Address - Phone:760-948-7400
Mailing Address - Fax:760-948-7866
Practice Address - Street 1:18151 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4907
Practice Address - Country:US
Practice Address - Phone:760-948-7400
Practice Address - Fax:760-948-7866
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3433213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E34330Medicaid
480031711OtherRR MEDICARE
T11690Medicare UPIN
CA000E34330Medicaid