Provider Demographics
NPI:1881727303
Name:CRISCUOLO, MATTHEW JOHN (DPT)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:JOHN
Last Name:CRISCUOLO
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 50128
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-0128
Mailing Address - Country:US
Mailing Address - Phone:718-815-7050
Mailing Address - Fax:718-815-4889
Practice Address - Street 1:554 TOMPKINS AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1745
Practice Address - Country:US
Practice Address - Phone:718-815-7050
Practice Address - Fax:844-815-4889
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY027566-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03163444Medicaid
615364600OtherFECA
NY26-3857727OtherMETROPLUS
615364600OtherEEOIC
NY101222000088OtherFIDELIS
NYPT027566-9OtherNYS WORKERS COMPENSATION BOARD