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General NPI Number Information
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NPI Number | 1952395782
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Entity Type | Individual
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Provider Name | LARRY VAN THOMAS CRISCO MD
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Gender | Male
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 08/30/2019
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Provider Practice Location Address
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Address Line | 3901 UNIVERSITY BLVD S SUITE 221
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4392
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Country | US
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Telephone | 904-423-0010
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Fax | 904-423-0012
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Provider Business Mailing Address
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Address Line | 3901 UNIVERSITY BLVD S SUITE 221
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City | JACKSONVILLE
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State | FL
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Zip | 32216-4392
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Country | US
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Telephone | 904-423-0010
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Fax | 904-423-0012
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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 | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | 038457
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number | ME115672
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | 38457
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License Number State | GA
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Taxonomy #4
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Taxonomy Code | 207UN0901X
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Taxonomy Name | Nuclear Cardiology Physician
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License Number | 38457
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License Number State | GA
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Taxonomy #5
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Taxonomy Code | 207UN0902X
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Taxonomy Name | Nuclear Imaging & Therapy Physician
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License Number | 38457
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License Number State | GA
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Taxonomy #6
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Taxonomy Code | 207RI0011X
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Taxonomy Name | Interventional Cardiology Physician
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License Number | ME115672
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License Number State | FL
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