Provider Demographics
NPI:1700218054
Name:GUELDNER, CRYSTAL GAYLE (OD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:GAYLE
Last Name:GUELDNER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:GAYLE
Other - Last Name:LONGORIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 2128
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2128
Mailing Address - Country:US
Mailing Address - Phone:361-649-9535
Mailing Address - Fax:
Practice Address - Street 1:139 W OAK ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-3328
Practice Address - Country:US
Practice Address - Phone:985-467-1223
Practice Address - Fax:985-467-0979
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1666-700T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist