Provider Demographics
NPI:1962533257
Name:CROSSETTE, PAUL CHANMUGAM (MD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:CHANMUGAM
Last Name:CROSSETTE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PANCHAHARAN
Other - Middle Name:
Other - Last Name:CHANMUGAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9430
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-9430
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1055 SAXON BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8468
Practice Address - Country:US
Practice Address - Phone:386-917-5025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86634207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277727400Medicaid
FL93172OtherBLUE CROSS
FL93172OtherBLUE CROSS
H38521Medicare UPIN
FL277727400Medicaid