Provider Demographics
NPI:1124883012
Name:CRISWELL, KYLE (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:CRISWELL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5580 CALLE VISTA ALEGRE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887-2401
Mailing Address - Country:US
Mailing Address - Phone:714-640-9283
Mailing Address - Fax:
Practice Address - Street 1:4815 N ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6185
Practice Address - Country:US
Practice Address - Phone:509-434-7032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist