Provider Demographics
NPI:1972025302
Name:WEN, CRYSTAL WANG (OD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:WANG
Last Name:WEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:T
Other - Last Name:WANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:200 MINOR LANE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-0001
Mailing Address - Country:US
Mailing Address - Phone:510-642-2020
Mailing Address - Fax:510-642-8012
Practice Address - Street 1:200 MINOR LANE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-2020
Practice Address - Country:US
Practice Address - Phone:510-642-2020
Practice Address - Fax:510-642-8012
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9284152W00000X
CA33916TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist