Provider Demographics
NPI:1194736611
Name:COLE, KRISTINE (OD)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:COLE
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 1:5151 N PALM AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704-2221
Mailing Address - Country:US
Mailing Address - Phone:559-229-7202
Mailing Address - Fax:559-229-2998
Practice Address - Street 1:5151 N PALM AVE STE 150
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704-2221
Practice Address - Country:US
Practice Address - Phone:559-229-7202
Practice Address - Fax:559-229-2998
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6426T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064260Medicaid
CAU37183Medicare UPIN