Provider Demographics
NPI:1316910953
Name:KVEDAR, VICKI SHANGRAW (MD)
Entity type:Individual
Prefix:DR
First Name:VICKI
Middle Name:SHANGRAW
Last Name:KVEDAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:12 GREY LN
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1240
Mailing Address - Country:US
Mailing Address - Phone:781-334-6316
Mailing Address - Fax:781-334-6196
Practice Address - Street 1:467 MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3856
Practice Address - Country:US
Practice Address - Phone:781-662-2216
Practice Address - Fax:781-662-2297
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA59738207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3078418Medicaid
MAJ11132Medicare ID - Type Unspecified
MAE85571Medicare UPIN