Healthcare Provider Details

I. General information

NPI: 1790123487
Provider Name (Legal Business Name): JASON CRESPO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2013
Last Update Date: 04/17/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 W COPELAND DR
ORLANDO FL
32806-2101
US

IV. Provider business mailing address

125 W COPELAND DR
ORLANDO FL
32806-2101
US

V. Phone/Fax

Practice location:
  • Phone: 218-417-0903
  • Fax: 321-843-2267
Mailing address:
  • Phone: 218-417-0903
  • Fax: 321-843-2267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number266170
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME144916
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: