MEDICARE: DR. CHARLES RAY CRISPEN JR. D.O.

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	208000000X	Pediatrics Physician	DO14538	OR
2	208000000X	Pediatrics Physician	DO1575	NV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1750365409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES RAY CRISPEN JR. D.O.

Provider Business Mailing Address
First Line	:	2604 HIGH RANGE DRIVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134
Country	:	US
Telephone Number	:	702-522-9203
Fax Number	:

Provider Business Practice Location Address
First Line	:	2604 HIGH RANGE DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-7564
Country	:	US
Telephone Number	:	702-522-9203
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2005
Last Update Date	:	04/17/2014

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Directions to “ DR. CHARLES RAY CRISPEN JR. D.O.” Practice Location

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