Provider Demographics
NPI:1154843779
Name:MAKEDONSKY, KATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:MAKEDONSKY
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 1:1234 MOUNTAIN SIDE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94521-5508
Mailing Address - Country:US
Mailing Address - Phone:925-457-8632
Mailing Address - Fax:
Practice Address - Street 1:668B FREMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-4812
Practice Address - Country:US
Practice Address - Phone:650-948-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT33727TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist