Healthcare Provider Details

I. General information

NPI: 1093052326
Provider Name (Legal Business Name): KIMBERLY CRYSTLE VAZQUEZ O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 PEACHTREE DUNWOODY RD SUITE 300
ATLANTA GA
30342
US

IV. Provider business mailing address

1302 WALTON LN SE
SMYRNA GA
30082-3874
US

V. Phone/Fax

Practice location:
  • Phone: 404-257-0814
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT002718
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: