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General NPI Number Information
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NPI Number | 1619947033
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Entity Type | Individual
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Provider Name | MARK A CRISWELL M.D., F.A.C.S.
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Gender | Male
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Dates
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Enumeration Date | 01/26/2006
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Last Update Date | 07/11/2018
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Provider Practice Location Address
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Address Line | 307 BOATNER RD STE 114
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City | EGLIN AFB
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State | FL
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Zip | 32542
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Country | US
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Telephone | 850-883-8264
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Fax |
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Provider Business Mailing Address
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Address Line | 307 BOATNER RD STE 114
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City | EGLIN AFB
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State | FL
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Zip | 32542-1302
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Country | US
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Telephone | 850-883-8264
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 01046367A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 207YS0012X
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Taxonomy Name | Sleep Medicine (Otolaryngology) Physician
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License Number | 01046367A
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License Number State | IN
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Taxonomy #3
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Taxonomy Code | 207YX0007X
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Taxonomy Name | Plastic Surgery within the Head & Neck (Otolaryngology) Physician
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License Number | 0056111
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License Number State | CO
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Taxonomy #4
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | 00056111
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License Number State | CO
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