Provider Demographics
NPI:1043285398
Name:GUALBERTO, CRISANTO (MD)
Entity type:Individual
Prefix:DR
First Name:CRISANTO
Middle Name:
Last Name:GUALBERTO
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 1:106 W STATE STREET
Mailing Address - Street 2:
Mailing Address - City:VANDALIA
Mailing Address - State:MO
Mailing Address - Zip Code:63382-1239
Mailing Address - Country:US
Mailing Address - Phone:573-594-6208
Mailing Address - Fax:
Practice Address - Street 1:106 W STATE STREET
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:MO
Practice Address - Zip Code:63382
Practice Address - Country:US
Practice Address - Phone:573-594-6208
Practice Address - Fax:573-594-6780
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR6651208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
A11087Medicare UPIN