Provider Demographics
NPI:1104496538
Name:TEDRICK, HEIDI KRISTINE (OD)
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:KRISTINE
Last Name:TEDRICK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEIDI
Other - Middle Name:KRISTINE
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:1601 KIRKWOOD HWY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-4917
Practice Address - Country:US
Practice Address - Phone:302-994-2511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003785152W00000X
DEI3-0011441152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist