Provider Demographics
NPI:1225228497
Name:KEAVENEY, KATHERINE M (OD)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:M
Last Name:KEAVENEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:KATHERINE
Other - Middle Name:M
Other - Last Name:KEAVENEY-REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3990
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:703-991-0514
Practice Address - Street 1:3101 SHANNON RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-3571
Practice Address - Country:US
Practice Address - Phone:919-493-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1369152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU19647Medicare UPIN