MEDICARE: DR. CRAIG LEON ABBOTT M.D.

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	207N00000X	Dermatology Physician	17800	OK
2	207ND0101X	MOHS-Micrographic Surgery Physician	17800	OK
3	207NS0135X	Procedural Dermatology Physician	17800	OK
4	207ND0900X	Dermatopathology Physician	17800	OK

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
2	541511960-003	OTHER	OK	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1962453795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRAIG LEON ABBOTT M.D.

Provider Business Mailing Address
First Line	:	801 YORK ST
Second Line	:
City	:	MANITOWOC
State	:	WI
Zip	:	54220-4630
Country	:	US
Telephone Number	:	920-663-9008
Fax Number	:	920-684-1439

Provider Business Practice Location Address
First Line	:	3500 S WESTERN AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73109-2413
Country	:	US
Telephone Number	:	405-632-5565
Fax Number	:	405-632-3538

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

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	06/30/2021

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