1366165094 NPI number — DR. JEREDINE M KALLON OD

Table of content: DR. JEREDINE M KALLON OD (NPI 1366165094)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366165094 NPI number — DR. JEREDINE M KALLON OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KALLON
Provider First Name:
JEREDINE
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366165094
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 208869
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75320-8869
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-200-4393
Provider Business Mailing Address Fax Number:
636-527-0766

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14 CONSULTANT PL STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27707-6326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-493-3668
Provider Business Practice Location Address Fax Number:
919-490-5594
Provider Enumeration Date:
09/19/2022

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  2812 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: NA4048B . This is a "MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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