Provider Demographics
NPI:1730768243
Name:CRISP, CORDELL WESTON (MD)
Entity type:Individual
Prefix:
First Name:CORDELL
Middle Name:WESTON
Last Name:CRISP
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 1:1649 HIGHWAY 64 E
Mailing Address - Street 2:
Mailing Address - City:BALD KNOB
Mailing Address - State:AR
Mailing Address - Zip Code:72010-3938
Mailing Address - Country:US
Mailing Address - Phone:501-283-0280
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7199
Practice Address - Country:US
Practice Address - Phone:501-686-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-03
Last Update Date:2021-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program