Provider Demographics
NPI:1235103508
Name:VEDOCK, KATHLEEN JANE (DO, FAAP)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:JANE
Last Name:VEDOCK
Suffix:
Gender:F
Credentials:DO, FAAP
Other - Prefix:
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Mailing Address - Street 1:1205 F AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:AZ
Mailing Address - Zip Code:85607-1920
Mailing Address - Country:US
Mailing Address - Phone:520-364-6852
Mailing Address - Fax:520-364-4261
Practice Address - Street 1:155 CALLE PORTAL
Practice Address - Street 2:SUITE 700
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2900
Practice Address - Country:US
Practice Address - Phone:520-459-0203
Practice Address - Fax:520-364-4261
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ3952208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ807125Medicaid
AZ807125Medicaid