Provider Demographics
NPI:1407465057
Name:DIFUNTORUM, KRISTIN (OD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:DIFUNTORUM
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 1:333 SANTA FE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-5327
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 N NELLIS BLVD STE B
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-6003
Practice Address - Country:US
Practice Address - Phone:702-360-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-29
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1072152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist