Provider Demographics
NPI:1447734330
Name:KEDDIS, DIANA
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KEDDIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 PORT RICHMOND AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-1749
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 PORT RICHMOND AVE STE B
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-1740
Practice Address - Country:US
Practice Address - Phone:718-556-0942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333600000XSuppliersPharmacy