Provider Demographics
NPI:1306069265
Name:CRISPELL, CAROLYN DIANE (DO)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DIANE
Last Name:CRISPELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3708 JEFFERSON ST
Mailing Address - Street 2:STE A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-6206
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:607-729-3982
Practice Address - Street 1:33-57 HARRISON ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2107
Practice Address - Country:US
Practice Address - Phone:607-763-6622
Practice Address - Fax:607-763-5064
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239067208M00000X, 207R00000X
TXR7696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02886620Medicaid
NYRB4728Medicare PIN