Healthcare Provider Details

I. General information

NPI: 1326483405
Provider Name (Legal Business Name): CRYSTAL WADE LDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 05/31/2026
Certification Date: 05/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 HIGHWAY 54 W STE 307
FAYETTEVILLE GA
30214-4563
US

IV. Provider business mailing address

7492 PARKLAND BND
FAIRBURN GA
30213-5422
US

V. Phone/Fax

Practice location:
  • Phone: 678-834-7411
  • Fax: 678-834-7414
Mailing address:
  • Phone: 678-777-1824
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FC0800X
TaxonomyContact Lens Technician/Technologist
License NumberLDO002220
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License NumberLDO002220
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT3743
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License NumberOPT3743
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: