Provider Demographics
NPI:1619455631
Name:TOM, CRYSTAL KIMIKO (OD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:KIMIKO
Last Name:TOM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:KIMIKO
Other - Last Name:KAWANO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7075 N SHARON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3329
Mailing Address - Country:US
Mailing Address - Phone:559-486-2000
Mailing Address - Fax:559-256-8595
Practice Address - Street 1:7075 N SHARON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3329
Practice Address - Country:US
Practice Address - Phone:559-486-2000
Practice Address - Fax:559-256-8595
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34158TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist