Provider Demographics
NPI:1992872691
Name:KEDDINGTON, JOAN (OD)
Entity type:Individual
Prefix:DR
First Name:JOAN
Middle Name:
Last Name:KEDDINGTON
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 1:1773 COUNTRY VISTAS LN
Mailing Address - Street 2:
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902-3076
Mailing Address - Country:US
Mailing Address - Phone:619-421-8929
Mailing Address - Fax:619-271-6315
Practice Address - Street 1:1481 E PLAZA BLVD
Practice Address - Street 2:
Practice Address - City:NATIONAL CITY
Practice Address - State:CA
Practice Address - Zip Code:91950-3613
Practice Address - Country:US
Practice Address - Phone:619-477-2159
Practice Address - Fax:619-477-2128
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6263T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0062630Medicaid
CAW19760Medicare PIN
CAT79389Medicare UPIN