Provider Demographics
NPI:1962886283
Name:VANICHSARN, KRYSTAL TAN (OD)
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:TAN
Last Name:VANICHSARN
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 1:12614 CROWN CREST DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-8567
Mailing Address - Country:US
Mailing Address - Phone:408-315-0505
Mailing Address - Fax:
Practice Address - Street 1:700 W EL NORTE PKWY STE 200
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-3923
Practice Address - Country:US
Practice Address - Phone:607-435-8727
Practice Address - Fax:760-743-5879
Is Sole Proprietor?:No
Enumeration Date:2015-07-16
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003091152W00000X
CA15449152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist