Healthcare Provider Details

I. General information

NPI: 1821106295
Provider Name (Legal Business Name): GUILLERMO V CRISOLOGO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JEFFERSON ST
PORT CLINTON OH
43452-2413
US

IV. Provider business mailing address

620 JEFFERSON ST
PORT CLINTON OH
43452-2413
US

V. Phone/Fax

Practice location:
  • Phone: 419-734-3116
  • Fax: 419-734-5786
Mailing address:
  • Phone: 419-734-3116
  • Fax: 419-734-5786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35-032803
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: