Basic Information
| Provider Information | |||||||||
| NPI: | 1417277716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISOSTOMO | ||||||||
| FirstName: | EUGENE | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHYSICAL THERAPIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 FLORADAN RD | ||||||||
| Address2: | |||||||||
| City: | PUTNAM VALLEY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10579 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9177740217 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 EAST 149TH ST. | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186657565 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 06/09/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 024878 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 024878 | 01 | NY | PT LICENSE | OTHER |