Provider Demographics
NPI:1861419319
Name:CRISCOLA, DAVID BRIAN (PT)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRIAN
Last Name:CRISCOLA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 W LINCOLN TRAIL BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2671
Mailing Address - Country:US
Mailing Address - Phone:270-352-1061
Mailing Address - Fax:270-352-1067
Practice Address - Street 1:800 W LINCOLN TRAIL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2671
Practice Address - Country:US
Practice Address - Phone:270-352-1061
Practice Address - Fax:270-352-1067
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004308225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50000935OtherPASSPORT HEALTH
KY8700086500Medicaid
KY000000238482OtherBCBS
KY1861419319OtherRAIL ROAD MEDICARE
KY50000935OtherPASSPORT HEALTH