Healthcare Provider Details

I. General information

NPI: 1225036528
Provider Name (Legal Business Name): DONNA R CRISCENZO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 GOOSE LANE
GUILFORD CT
06437-2115
US

IV. Provider business mailing address

199 GOOSE LANE
GUILFORD CT
06437-2115
US

V. Phone/Fax

Practice location:
  • Phone: 203-458-2888
  • Fax: 203-458-2889
Mailing address:
  • Phone: 203-458-2888
  • Fax: 203-458-2889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number022662
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: