Provider Demographics
NPI:1942555974
Name:LONG, KRYSTAL L (OD)
Entity Type:Individual
Prefix:DR
First Name:KRYSTAL
Middle Name:L
Last Name:LONG
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 1:3232 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3403
Mailing Address - Country:US
Mailing Address - Phone:701-280-3000
Mailing Address - Fax:701-280-1304
Practice Address - Street 1:3232 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3403
Practice Address - Country:US
Practice Address - Phone:701-280-3000
Practice Address - Fax:701-280-1304
Is Sole Proprietor?:No
Enumeration Date:2012-07-16
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH6140152W00000X
MN3297152W00000X
ND771152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist