Provider Demographics
NPI:1679533756
Name:CRISOSTOMO, RICARDO H (MD)
Entity type:Individual
Prefix:
First Name:RICARDO
Middle Name:H
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:RICARDO
Other - Last Name:CRISOSTOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 MERCADO ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7306
Mailing Address - Country:US
Mailing Address - Phone:970-385-7977
Mailing Address - Fax:970-385-6727
Practice Address - Street 1:1 MERCARDO ST.
Practice Address - Street 2:STE 100
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-7306
Practice Address - Country:US
Practice Address - Phone:970-385-7977
Practice Address - Fax:970-385-6727
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0067681207RH0003X
FLME89846207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272461800Medicaid
FL29551ZMedicare PIN
I44765Medicare UPIN