Provider Demographics
NPI:1720021413
Name:CRISTALES, QUIRICO G (MD)
Entity Type:Individual
Prefix:DR
First Name:QUIRICO
Middle Name:G
Last Name:CRISTALES
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 1:1289 E LIVINGSTON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43205-2838
Mailing Address - Country:US
Mailing Address - Phone:614-252-0917
Mailing Address - Fax:614-252-6153
Practice Address - Street 1:1289 E LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43205-2838
Practice Address - Country:US
Practice Address - Phone:614-252-0917
Practice Address - Fax:614-252-6153
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050342207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0560503Medicaid
OHCR0559131Medicare ID - Type Unspecified
OHA15905Medicare UPIN