Provider Demographics
NPI:1144292525
Name:CRISOSTOMO, RALPH (MD)
Entity type:Individual
Prefix:
First Name:RALPH
Middle Name:
Last Name:CRISOSTOMO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:975 SERENO DR
Mailing Address - Street 2:SPINE CLINIC H31
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2441
Mailing Address - Country:US
Mailing Address - Phone:707-651-1000
Mailing Address - Fax:
Practice Address - Street 1:975 SERENO DR
Practice Address - Street 2:SPINE CLINIC H31
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2441
Practice Address - Country:US
Practice Address - Phone:707-651-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA104669208100000X
AZ368212084N0400X
MI4301092351208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN356952700Medicaid
I35683Medicare UPIN
MN250000677Medicare ID - Type Unspecified
MN356952700Medicaid