MEDICARE: DR. KRYSTEN L AVERY 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	TPOP10	FL
2	152W00000X	Optometrist	4901004395	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770670697
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRYSTEN L AVERY O.D.

Provider Business Mailing Address
First Line	:	8256 NADELL ST
Second Line	:
City	:	DELTON
State	:	MI
Zip	:	49046-8202
Country	:	US
Telephone Number	:	269-267-7902
Fax Number	:

Provider Business Practice Location Address
First Line	:	1979 MARCUS AVE STE 206
Second Line	:
City	:	NORTH NEW HYDE PARK
State	:	NY
Zip	:	11042-1002
Country	:	US
Telephone Number	:	877-506-0002
Fax Number	:

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

Provider Enumeration Date	:	10/10/2006
Last Update Date	:	06/07/2021

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