Provider Demographics
NPI:1447231089
Name:WOODWARD, KRISTINA STASKO (OD)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:STASKO
Last Name:WOODWARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:STASKO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1234 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3110
Mailing Address - Country:US
Mailing Address - Phone:560-593-1661
Mailing Address - Fax:650-595-5203
Practice Address - Street 1:1234 CHERRY ST
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-3110
Practice Address - Country:US
Practice Address - Phone:560-593-1661
Practice Address - Fax:650-595-5203
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8031T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAYYY48725YMedicaid
CA1238570001OtherMEDICARE SUPPLY
CAYYY48725YMedicaid
CA1238570001OtherMEDICARE SUPPLY