1477606945 NPI number — KIMBERLY A TEDDER O.D.

Table of content: KIMBERLY A TEDDER O.D. (NPI 1477606945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477606945 NPI number — KIMBERLY A TEDDER O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEDDER
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POZZA
Provider Other First Name:
KIMBERLY
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477606945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14159 ONEIDA CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORPARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93021-3565
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-529-3116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
766 LOS ANGELES AVE
Provider Second Line Business Practice Location Address:
SUITE D3
Provider Business Practice Location Address City Name:
MOORPARK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-523-3440
Provider Business Practice Location Address Fax Number:
805-523-3442
Provider Enumeration Date:
01/19/2007

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:  13135T , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1477606945 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1477606945 . This is a "ANTHEM BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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