Basic Information
| Provider Information | |||||||||
| NPI: | 1801059514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTOBAL | ||||||||
| FirstName: | RICARDO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6320 SOUTHWEST BLVD. | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177665500 | ||||||||
| FaxNumber: | 8177665501 | ||||||||
| Practice Location | |||||||||
| Address1: | 6320 SOUTHWEST BLVD | ||||||||
| Address2: | SUITE #200 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177665500 | ||||||||
| FaxNumber: | 8177665501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2008 | ||||||||
| LastUpdateDate: | 02/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YX0901X | M9939 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otology & Neurotology | 207Y00000X | M9939 | TX | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 196011402 | 01 | TX | CSHCN MEDICAID | OTHER | P00643338 | 01 | TX | RAIL ROAD MEDICARE | OTHER | 196011401 | 05 | TX | MEDICAID |