Provider Demographics
NPI:1003921180
Name:BERTHELETTE, KRYSTAL LEIGH (OD)
Entity Type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:LEIGH
Last Name:BERTHELETTE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:KRYSTAL
Other - Middle Name:LEIGH
Other - Last Name:JOYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:119 LATONEA DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-7572
Mailing Address - Country:US
Mailing Address - Phone:803-798-8642
Mailing Address - Fax:803-798-8642
Practice Address - Street 1:5420 FOREST DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29206-5401
Practice Address - Country:US
Practice Address - Phone:803-790-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist