Healthcare Provider Details

I. General information

NPI: 1407959554
Provider Name (Legal Business Name): CRISMALI PODIATRIC MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 05/02/2025
Certification Date: 05/02/2025
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: PETER AWAD
Title or Position: CEO
Credential: DPM
Phone: 760-948-7400