Provider Demographics
NPI:1386744977
Name:MOSTELLER, CRYSTAL YVONNE (OD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:YVONNE
Last Name:MOSTELLER
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: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
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2491152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200109170AMedicaid
OK200109170AMedicaid
OK200109170AMedicaid
OK5971380001Medicare NSC