Provider Demographics
NPI:1467003061
Name:OMI, KRISTEN MIDORI
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MIDORI
Last Name:OMI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HAMMOND PLZ
Mailing Address - Street 2:
Mailing Address - City:BEACON
Mailing Address - State:NY
Mailing Address - Zip Code:12508-3139
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:845-938-2206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT34345-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist