MEDICARE: DONNA R. CRISCENZO, M.D., LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	022662	CT

General Provider Information

NPI Number	:	1639353907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DONNA R. CRISCENZO, M.D., LLC

Provider Business Mailing Address
First Line	:	199 GOOSE LN
Second Line	:
City	:	GUILFORD
State	:	CT
Zip	:	06437-2115
Country	:	US
Telephone Number	:	203-458-2888
Fax Number	:	203-458-2889

Provider Business Practice Location Address
First Line	:	199 GOOSE LN
Second Line	:
City	:	GUILFORD
State	:	CT
Zip	:	06437-2115
Country	:	US
Telephone Number	:	203-458-2888
Fax Number	:	203-458-2889

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DONNA R. CRISCENZO
Credential	:	M.D.
Telephone Number	:	203-458-2888

Provider Enumeration Date	:	12/21/2007
Last Update Date	:	12/21/2007

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