Provider Demographics
NPI:1053370056
Name:DICRISTOFARO, SEAN CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:CHARLES
Last Name:DICRISTOFARO
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 1:104 STATION PLACE WAY
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-8747
Mailing Address - Country:US
Mailing Address - Phone:304-757-7788
Mailing Address - Fax:304-201-1140
Practice Address - Street 1:104 STATION PLACE WAY
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-8747
Practice Address - Country:US
Practice Address - Phone:304-757-7788
Practice Address - Fax:304-201-1140
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-20
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV19679174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV5630468000Medicaid
H19538Medicare UPIN
WV5630468000Medicaid