Provider Demographics
NPI:1477606945
Name:TEDDER, KIMBERLY A (OD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:TEDDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:A
Other - Last Name:POZZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14159 ONEIDA CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3565
Mailing Address - Country:US
Mailing Address - Phone:805-529-3116
Mailing Address - Fax:
Practice Address - Street 1:766 LOS ANGELES AVE
Practice Address - Street 2:SUITE D3
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021
Practice Address - Country:US
Practice Address - Phone:805-523-3440
Practice Address - Fax:805-523-3442
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13135T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1477606945Medicaid
1477606945OtherANTHEM BLUE CROSS
CA1477606945Medicaid
1477606945Medicare NSC