Provider Demographics
NPI:1588841365
Name:CHEN, CRYSTAL I (OD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:I
Last Name:CHEN
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 1:42622 SHOREHAM PARK CT
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-4034
Mailing Address - Country:US
Mailing Address - Phone:925-667-7754
Mailing Address - Fax:
Practice Address - Street 1:36 W YOKUTS AVE STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5713
Practice Address - Country:US
Practice Address - Phone:209-952-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-24
Last Update Date:2011-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12114152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist