Provider Demographics
NPI:1154408946
Name:KANG, CRYSTAL UNHE (OD)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:UNHE
Last Name:KANG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:UNHE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4530 VAN BUREN STREET
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737
Mailing Address - Country:US
Mailing Address - Phone:301-559-0090
Mailing Address - Fax:
Practice Address - Street 1:4530 VAN BUREN STREET
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737
Practice Address - Country:US
Practice Address - Phone:301-559-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA1178152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDTA1178OtherSTATE LIC. #
MDTA1178OtherSTATE LIC. #
VA1868OtherSTATE LIC #
MDLE510854Medicare ID - Type Unspecified