MEDICARE: CRYSTAL ARLENE GIBSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	14291	CA

General Provider Information

NPI Number	:	1295019735
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL ARLENE GIBSON O.D.

Provider Business Mailing Address
First Line	:	16152 WHITTIER BLVD
Second Line	:	STE A
City	:	WHITTIER
State	:	CA
Zip	:	90603-2940
Country	:	US
Telephone Number	:	562-947-9461
Fax Number	:

Provider Business Practice Location Address
First Line	:	10807 JERSEY AVE
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-4316
Country	:	US
Telephone Number	:	562-863-7678
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/03/2011
Last Update Date	:	08/09/2016

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