Provider Demographics
NPI:1043250103
Name:CRISWELL, DAN F (MD)
Entity type:Individual
Prefix:
First Name:DAN
Middle Name:F
Last Name:CRISWELL
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 1:2210 DUNCAN REGIONAL LOOP
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1564
Mailing Address - Country:US
Mailing Address - Phone:580-251-8212
Mailing Address - Fax:580-251-8842
Practice Address - Street 1:2601 W ELK AVE
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1572
Practice Address - Country:US
Practice Address - Phone:580-251-6644
Practice Address - Fax:580-251-6645
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12155207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100088900EMedicaid
OK$$$$$$$$$003OtherBLUE CROSS BLUE SHIELD
C94812Medicare UPIN