Provider Demographics
NPI:1992321616
Name:CREADORE, KRISTINA MARIE (OD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MARIE
Last Name:CREADORE
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 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:434-295-1000
Mailing Address - Fax:434-972-4266
Practice Address - Street 1:1300 JEFFERSON PARK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-3363
Practice Address - Country:US
Practice Address - Phone:434-924-5485
Practice Address - Fax:434-244-9436
Is Sole Proprietor?:No
Enumeration Date:2020-06-18
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV009330152W00000X
VA0618002903152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist