Healthcare Provider Details

I. General information

NPI: 1255405882
Provider Name (Legal Business Name): NICHOLAS C CRISMALI DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18151 BEAR VALLEY RD
HESPERIA CA
92345-4907
US

IV. Provider business mailing address

18151 BEAR VALLEY RD
HESPERIA CA
92345-4907
US

V. Phone/Fax

Practice location:
  • Phone: 760-948-7400
  • Fax: 760-948-7866
Mailing address:
  • Phone: 760-948-7400
  • Fax: 760-948-7866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3433
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE3433
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: