Healthcare Provider Details

I. General information

NPI: 1881727303
Provider Name (Legal Business Name): MATTHEW JOHN CRISCUOLO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 12/28/2023
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

554 TOMPKINS AVE
STATEN ISLAND NY
10305-1745
US

IV. Provider business mailing address

PO BOX 50128
STATEN ISLAND NY
10305-0128
US

V. Phone/Fax

Practice location:
  • Phone: 718-815-7050
  • Fax: 844-815-4889
Mailing address:
  • Phone: 718-815-7050
  • Fax: 718-815-4889

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number027566-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: