Provider Demographics
NPI:1952395782
Name:CRISCO, LARRY VAN THOMAS (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:VAN THOMAS
Last Name:CRISCO
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 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 221
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4392
Mailing Address - Country:US
Mailing Address - Phone:904-423-0010
Mailing Address - Fax:904-423-0012
Practice Address - Street 1:3901 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 221
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4392
Practice Address - Country:US
Practice Address - Phone:904-423-0010
Practice Address - Fax:904-423-0012
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038457207RC0000X
FLME115672207RC0000X, 207RI0011X
GA38457207RI0011X, 207UN0901X, 207UN0902X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
No207UN0902XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Imaging & Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000777686GMedicaid
GA58-1624987OtherTAX ID#
1952395782OtherNPI
GA58-1624987OtherTAX ID#
FLF67643Medicare UPIN
GA000777686GMedicaid