Provider Demographics
NPI:1356397863
Name:CHRESTMAN, REUBEN L III (MD)
Entity type:Individual
Prefix:DR
First Name:REUBEN
Middle Name:L
Last Name:CHRESTMAN
Suffix:III
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 1:3507 BLUE BIRD LN
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-8690
Mailing Address - Country:US
Mailing Address - Phone:662-287-6711
Mailing Address - Fax:
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:DEPT. OF RADIOLOGY
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9368
Practice Address - Country:US
Practice Address - Phone:662-293-1466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS173882085R0202X
TN71262085R0202X
LA03187R2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1199001Medicaid
AC5343316OtherDEA
B62175Medicare UPIN
LA1199001Medicaid