Basic Information
| Provider Information | |||||||||
| NPI: | 1881633568 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CRESPO | ||||||||
| FirstName: | JORGE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 910 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 013020910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4137728500 | ||||||||
| FaxNumber: | 4137728900 | ||||||||
| Practice Location | |||||||||
| Address1: | 745A ROUTE 63 | ||||||||
| Address2: | |||||||||
| City: | CHESTERFIELD | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034433604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003038984 | ||||||||
| FaxNumber: | 6033634450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 8345 | NH | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 8233 | 01 | VT | BC/BS VT | OTHER | 0104793Y0VT01 | 01 | NH | BC/BS NH | OTHER | 30003577 | 05 | NH | MEDICAID | OVN2029 | 05 | VT | MEDICAID |