Provider Demographics
NPI:1053920546
Name:WIDJAJA, CHRISTA MARIE (OD)
Entity type:Individual
Prefix:DR
First Name:CHRISTA
Middle Name:MARIE
Last Name:WIDJAJA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 COIT RD
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75023-5959
Mailing Address - Country:US
Mailing Address - Phone:972-985-1412
Mailing Address - Fax:972-945-2125
Practice Address - Street 1:5900 COIT RD
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75023-5959
Practice Address - Country:US
Practice Address - Phone:972-985-1412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-30
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9933152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX4215477Medicaid