Provider Demographics
NPI:1114159225
Name:FORDOSKI, KRYSTAL MARIE (OD)
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MARIE
Last Name:FORDOSKI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STATE ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1429
Mailing Address - Country:US
Mailing Address - Phone:814-453-4575
Mailing Address - Fax:144-593-8858
Practice Address - Street 1:300 STATE ST STE 200
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1429
Practice Address - Country:US
Practice Address - Phone:814-453-4575
Practice Address - Fax:814-459-3885
Is Sole Proprietor?:No
Enumeration Date:2009-08-23
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002236152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist