Healthcare Provider Details

I. General information

NPI: 1881633568
Provider Name (Legal Business Name): JORGE LUIS CRESPO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745A ROUTE 63
CHESTERFIELD NH
03443-3604
US

IV. Provider business mailing address

PO BOX 910
GREENFIELD MA
01302-0910
US

V. Phone/Fax

Practice location:
  • Phone: 800-303-8984
  • Fax: 603-363-4450
Mailing address:
  • Phone: 413-772-8500
  • Fax: 413-772-8900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number8345
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: