Healthcare Provider Details

I. General information

NPI: 1144226135
Provider Name (Legal Business Name): MICHAEL ANGEL DICRISTINA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 06/08/2015
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 04/06/2006

III. Provider practice location address

33 UPPER RIVERDALE RD SW SUITE 21
RIVERDALE GA
30274-2626
US

IV. Provider business mailing address

33 UPPER RIVERDALE RD SW SUITE #21
RIVERDALE GA
30274-2626
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-7933
  • Fax: 770-968-6521
Mailing address:
  • Phone: 770-968-7933
  • Fax: 770-968-6521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number022223
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: