Healthcare Provider Details

I. General information

NPI: 1699047530
Provider Name (Legal Business Name): KRISTEN GLASGOW O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2320 MIDWAY DR
SANTA ROSA CA
95405
US

IV. Provider business mailing address

3247 SOLANO AVE
NAPA CA
94558-3255
US

V. Phone/Fax

Practice location:
  • Phone: 707-526-2020
  • Fax:
Mailing address:
  • Phone: 704-222-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number33833TLG
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: