Provider Demographics
NPI:1518025147
Name:KEDDIS, EVELYN N (MD)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:N
Last Name:KEDDIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 GATES CT
Mailing Address - Street 2:
Mailing Address - City:MORRIS PLAINS
Mailing Address - State:NJ
Mailing Address - Zip Code:07950-3485
Mailing Address - Country:US
Mailing Address - Phone:973-267-9792
Mailing Address - Fax:
Practice Address - Street 1:59 KOCH AVE
Practice Address - Street 2:
Practice Address - City:MORRIS PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07950-4400
Practice Address - Country:US
Practice Address - Phone:973-538-1800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA027756002084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJKE442740Medicare ID - Type Unspecified
NJC54607Medicare UPIN