Basic Information
| Provider Information | |||||||||
| NPI: | 1861467367 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRISPINO | ||||||||
| FirstName: | CARMINE | ||||||||
| MiddleName: | RAYMOND | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604427011 | ||||||||
| FaxNumber: | 8604445114 | ||||||||
| Practice Location | |||||||||
| Address1: | 365 MONTAUK AVE | ||||||||
| Address2: | |||||||||
| City: | NEW LONDON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063204700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604427011 | ||||||||
| FaxNumber: | 8604445114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 08/08/2013 | ||||||||
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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 | 207R00000X | 042164 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 042164 | CT | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 010042164CT03 | 01 | CT | BLUE CROSS | OTHER | P3227288 | 01 | OXFORD | OTHER | 001421643 | 05 | CT | MEDICAID |