Provider Demographics
NPI:1144063033
Name:CRISCUOLO, MICHAEL THOMAS (LO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:THOMAS
Last Name:CRISCUOLO
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 SUMMERFIELD GDNS
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6306
Mailing Address - Country:US
Mailing Address - Phone:203-213-4511
Mailing Address - Fax:
Practice Address - Street 1:465 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4751
Practice Address - Country:US
Practice Address - Phone:203-926-1189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1504156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician