Basic Information
| Provider Information | |||||||||
| NPI: | 1720347867 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISOSTOMO | ||||||||
| FirstName: | ABIGAIL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2580 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658012580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178294620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1605 MARTIN SPRINGS DR | ||||||||
| Address2: | STE 210 | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734586326 | ||||||||
| FaxNumber: | 5734586763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2012 | ||||||||
| LastUpdateDate: | 12/20/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2012003234 | MO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P01089883 | 01 | MO | RR MCR | OTHER | 431560263 | 01 | MO | TRICARE | OTHER | 1720347867 | 05 | MO | MEDICAID |