Provider Demographics
NPI:1215078399
Name:KRYSTAL, ALAN
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:KRYSTAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1582 W SAN MARCOS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4081
Mailing Address - Country:US
Mailing Address - Phone:760-591-9975
Mailing Address - Fax:
Practice Address - Street 1:1582 W SAN MARCOS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4081
Practice Address - Country:US
Practice Address - Phone:760-591-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-09
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG74558207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00290917OtherRAILROAD MEDICARE
CA00G745580Medicaid
CAP00290917OtherRAILROAD MEDICARE
CAH98693Medicare UPIN
CA00G745580Medicaid