ABIGAIL CRISOSTOMO, MD - NPI NUMBER 1720347867

Summary

Provider Name: ABIGAIL CRISOSTOMO, MD

NPI Number: 1720347867

Clasification: Family Medicine (207Q00000X)

Organization: MERCY CLINIC SPRINGFIELD COMMUNITIES

Address:
1605 MARTIN SPRINGS DR
STE 210
ROLLA, MO
ZIP 65401

Phone Number: (573) 458-6326



Detailed Information

Abigail Crisostomo, MD is a family physician in Rolla, MO with 11 years of experience. The provider is family Medicine is the medical specialty which is concerned with the total health care of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family medicine is not limited by age, sex, organ system, or disease entity. The assigned NPI number for this provider is 1720347867 and is registered as an individual entity type.

The NPPES NPI record indicates the provider is a female.

The provider's business address is:

1605 MARTIN SPRINGS DR
STE 210
ROLLA, MO
ZIP 65401-931
Phone: (573) 458-6326
Fax: (573) 458-6763

The enumeration date for this NPI number is 5/10/2012 and was last updated on 12/20/2012.

Map - Location of Practice

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Taxonomy Codes

The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1 207Q00000X Family Medicine 2012003234 MO Yes

Other (Legacy) Identifiers

The following legacy identifiers are available for this provider:

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1 1720347867 MEDICAID MO
2 431560263 OTHER MO TRICARE
3 P01089883 OTHER MO RR MCR
4 132300229 MEDICARE PIN MO

NPI Record

No. Field Name Field Value
1 NPI 1720347867
2 Entity Type Code 1
3 Provider Last Name Legal Name CRISOSTOMO
4 Provider First Name ABIGAIL
5 Provider Credential Text MD
6 Provider First Line Business Practice Location Address 1605 MARTIN SPRINGS DR
7 Provider Second Line Business Practice Location Address STE 210
8 Provider Business Practice Location Address City Name ROLLA
9 Provider Business Practice Location Address State Name MO
10 Provider Business Practice Location Address Postal Code 654012931
11 Provider Business Practice Location Address Country Code If outside U S US
12 Provider Business Practice Location Address Telephone Number 5734586326
13 Provider Business Practice Location Address Fax Number 5734586763
14 Provider Enumeration Date 5/10/2012
15 Last Update Date 12/20/2012
16 Provider Gender Code F
17 Healthcare Provider Taxonomy Code 1 207Q00000X
18 Provider License Number 1 2012003234
19 Provider License Number State Code 1 MO
20 Healthcare Provider Primary Taxonomy Switch 1 Y
21 Other Provider Identifier 1 1720347867
22 Other Provider Identifier Type Code 1 05
23 Other Provider Identifier State 1 MO
24 Other Provider Identifier 2 431560263
25 Other Provider Identifier Type Code 2 01
26 Other Provider Identifier State 2 MO
27 Other Provider Identifier Issuer 2 TRICARE
28 Other Provider Identifier 3 P01089883
29 Other Provider Identifier Type Code 3 01
30 Other Provider Identifier State 3 MO
31 Other Provider Identifier Issuer 3 RR MCR
32 Other Provider Identifier 4 132300229
33 Other Provider Identifier Type Code 4 08
34 Other Provider Identifier State 4 MO
35 Is Sole Proprietor N

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This page was last updated on: 11/14/2014
All materials and services on this site are provided on an "as is" and "as available" basis without warranty of any kind. The NPI record is maintained by the National Plan & Provider Enumeration System (NPPES) and anyone may request this information and other NPPES health care provider data from HHS under The Freedom of Information Act (FOIA), Title 5 of the United States Code, section 552. To update the NPI records please contact the NPPES.