Provider Demographics
NPI:1336349901
Name:GARDNER, CRYSTAL A (OD)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:A
Last Name:GARDNER
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 1:990 BEAR CREEK BLVD
Mailing Address - Street 2:STE. D
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-1864
Mailing Address - Country:US
Mailing Address - Phone:770-707-0711
Mailing Address - Fax:770-707-0811
Practice Address - Street 1:990 BEAR CREEK BLVD
Practice Address - Street 2:STE. D
Practice Address - City:HAMPTON
Practice Address - State:GA
Practice Address - Zip Code:30228-1864
Practice Address - Country:US
Practice Address - Phone:770-707-0711
Practice Address - Fax:770-707-0811
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT002401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist