Provider Demographics
NPI:1386953461
Name:EDISON, CRYSTAL MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:MARIE
Last Name:EDISON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:MARIE
Other - Last Name:INSAURRALDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:700 WATERFRONT WAY APT 726
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3534
Mailing Address - Country:US
Mailing Address - Phone:360-852-1984
Mailing Address - Fax:
Practice Address - Street 1:8700 NE VANCOUVER MALL DR STE 232
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6418
Practice Address - Country:US
Practice Address - Phone:360-882-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-06
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3987-35152W00000X
NE1635152W00000X
AZOPT-002711152W00000X
ORATI3504152W00000X
PAOEG004008152W00000X
WA60391130152W00000X
FLTPOP146152W00000X
GAOPT003534152W00000X
MDTA2910152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist