Provider Demographics
NPI:1538109590
Name:NGUYEN, KRYSTAL T (OD)
Entity Type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:T
Last Name:NGUYEN
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 1:6533 ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19149
Mailing Address - Country:US
Mailing Address - Phone:215-744-6727
Mailing Address - Fax:215-744-1622
Practice Address - Street 1:6533 ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149
Practice Address - Country:US
Practice Address - Phone:215-744-6727
Practice Address - Fax:215-744-1622
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000225152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2308658000OtherKEYSTONE HLTH PLAN E & PE
0181497000OtherKEYSTONE HLTH PLAN E & PE
PA3548372OtherAETNA GROUP
PA1626663OtherBCBS
D28112OtherBCBS
3550323OtherAETNA IND
PA183922Medicare PIN
3550323OtherAETNA IND