Provider Demographics
NPI:1780720847
Name:CRESCUILLO, JAMES P (DC CCSP)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:P
Last Name:CRESCUILLO
Suffix:
Gender:M
Credentials:DC CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 EAST CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050
Mailing Address - Country:US
Mailing Address - Phone:740-397-8025
Mailing Address - Fax:740-397-8025
Practice Address - Street 1:210 EAST CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050
Practice Address - Country:US
Practice Address - Phone:740-397-8025
Practice Address - Fax:740-397-8025
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1427111NS0005X
TX4189111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0856944Medicaid