Healthcare Provider Details

I. General information

NPI: 1679533756
Provider Name (Legal Business Name): RICARDO H CRISOSTOMO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOSE RICARDO CRISOSTOMO MD

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 01/05/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MERCARDO ST. STE 100
DURANGO CO
81301-7306
US

IV. Provider business mailing address

1 MERCADO ST STE 100
DURANGO CO
81301-7306
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-7977
  • Fax: 970-385-6727
Mailing address:
  • Phone: 970-385-7977
  • Fax: 970-385-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberDR.0067681
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME89846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: