Provider Demographics
NPI:1306806765
Name:CRISPELL, BRIAN DALE
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:DALE
Last Name:CRISPELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRIAN
Other - Middle Name:
Other - Last Name:CRISPELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:2301 GREEN ST
Mailing Address - Street 2:APT 8
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19130-3143
Mailing Address - Country:US
Mailing Address - Phone:610-334-7657
Mailing Address - Fax:
Practice Address - Street 1:1078 W BALTIMORE PIKE
Practice Address - Street 2:RIDDLE HEALTH CENTER 1, SUITE 209
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5105
Practice Address - Country:US
Practice Address - Phone:610-334-7657
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005698213E00000X, 213EP1101X, 213ES0000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1015531700005Medicaid
PA329832OtherMEDICARE PTAN