Healthcare Provider Details

I. General information

NPI: 1992237606
Provider Name (Legal Business Name): LAURA CRISCENZO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 07/16/2021
Certification Date: 07/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 COLUMBIA TPKE
FLORHAM PARK NJ
07932-2283
US

IV. Provider business mailing address

PO BOX 416457
BOSTON MA
02241-6457
US

V. Phone/Fax

Practice location:
  • Phone: 973-992-5588
  • Fax: 973-992-1005
Mailing address:
  • Phone: 844-362-1735
  • Fax: 973-290-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MB10814000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: