Provider Demographics
NPI:1407959554
Name:CRISMALI PODIATRIC MEDICAL CORPORATION
Entity type:Organization
Organization Name:CRISMALI PODIATRIC MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:AWAD
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-948-7400
Mailing Address - Street 1:18151 BEAR VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-4907
Mailing Address - Country:US
Mailing Address - Phone:760-948-7400
Mailing Address - Fax:760-948-7866
Practice Address - Street 1:18151 BEAR VALLEY RD
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-4907
Practice Address - Country:US
Practice Address - Phone:760-948-7400
Practice Address - Fax:760-948-7866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3433213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ66078ZOtherBLUE SHIELD
ZZZ02020ZMedicare ID - Type Unspecified
ZZZ66078ZOtherBLUE SHIELD