Healthcare Provider Details

I. General information

NPI: 1952395782
Provider Name (Legal Business Name): LARRY VAN THOMAS CRISCO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 08/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3901 UNIVERSITY BLVD S SUITE 221
JACKSONVILLE FL
32216-4392
US

IV. Provider business mailing address

3901 UNIVERSITY BLVD S SUITE 221
JACKSONVILLE FL
32216-4392
US

V. Phone/Fax

Practice location:
  • Phone: 904-423-0010
  • Fax: 904-423-0012
Mailing address:
  • Phone: 904-423-0010
  • Fax: 904-423-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number038457
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME115672
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number38457
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number38457
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code207UN0902X
TaxonomyNuclear Imaging & Therapy Physician
License Number38457
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberME115672
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: