Provider Demographics
NPI:1528076288
Name:KLAAHSEN, CRYSTAL J (OD)
Entity type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:J
Last Name:KLAAHSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:J
Other - Last Name:BARTOSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2038 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-2104
Mailing Address - Country:US
Mailing Address - Phone:617-864-3147
Mailing Address - Fax:617-864-4994
Practice Address - Street 1:2038 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-2104
Practice Address - Country:US
Practice Address - Phone:617-864-3147
Practice Address - Fax:617-864-4994
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4567152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA272710774OtherTRICARE
MAA04719OtherEYEMED VISION CARE
MAW16488OtherBLUE CROSS BLUE SHIELD
MA7488993OtherCIGNA
MAAA184459OtherHARVARD PILGRIM HEALTH CARE
MA7488993OtherCIGNA
MA0015994Medicare UPIN