Healthcare Provider Details

I. General information

NPI: 1265069967
Provider Name (Legal Business Name): LUIS ARIEL CRESPO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4730 N HABANA AVE STE 104
TAMPA FL
33614-7165
US

IV. Provider business mailing address

PO BOX 947387
ATLANTA GA
30394-7387
US

V. Phone/Fax

Practice location:
  • Phone: 813-739-7498
  • Fax:
Mailing address:
  • Phone: 813-739-7498
  • Fax: 813-425-9046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME168250
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberME168250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: