Provider Demographics
NPI:1588246284
Name:FAME, CRYSTAL (DO)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:FAME
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2212 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3870
Mailing Address - Country:US
Mailing Address - Phone:714-618-9540
Mailing Address - Fax:
Practice Address - Street 1:2212 E 4TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3870
Practice Address - Country:US
Practice Address - Phone:714-618-9540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A22816207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty