Provider Demographics
NPI:1952431439
Name:CRYSTAL Y MOSTELLER O D INC PC
Entity Type:Organization
Organization Name:CRYSTAL Y MOSTELLER O D INC PC
Other - Org Name:TUTTLE FAMILY EYECARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:MOSTELLER
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:405-381-2244
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:TUTTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73089-1377
Mailing Address - Country:US
Mailing Address - Phone:405-381-2244
Mailing Address - Fax:405-381-2246
Practice Address - Street 1:206 E MAIN ST
Practice Address - Street 2:
Practice Address - City:TUTTLE
Practice Address - State:OK
Practice Address - Zip Code:73089-9138
Practice Address - Country:US
Practice Address - Phone:405-381-2244
Practice Address - Fax:405-381-2246
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2012-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109170AMedicaid
OK200109170AMedicaid
OK5971380001Medicare NSC
OK600522379Medicare PIN