Healthcare Provider Details

I. General information

NPI: 1780319566
Provider Name (Legal Business Name): CRISTIAN JAVIER DAVALOS CRISTELLOT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

982 E MAIN ST
BRIDGEPORT CT
06608-1913
US

IV. Provider business mailing address

982 E MAIN ST
BRIDGEPORT CT
06608-1913
US

V. Phone/Fax

Practice location:
  • Phone: 646-431-6217
  • Fax:
Mailing address:
  • Phone: 203-608-3498
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number82483
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: