Provider Demographics
NPI:1104032002
Name:KVEDERIS, KATHRYN ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANNE
Last Name:KVEDERIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 DRUID HILL DR
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315-2122
Mailing Address - Country:US
Mailing Address - Phone:515-457-8030
Mailing Address - Fax:515-244-2507
Practice Address - Street 1:3105 DRUID HILL DR
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315-2122
Practice Address - Country:US
Practice Address - Phone:515-457-8030
Practice Address - Fax:515-244-2507
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA307402084P0804X
CAG546072084P0804X
NC2005-04252084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
01413Medicare ID - Type Unspecified
E02756Medicare UPIN