Provider Demographics
NPI:1578682977
Name:JOEDICKE, KELLY L (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:JOEDICKE
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:3910 CENTREVILLE RD
Mailing Address - Street 2:#100
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-3279
Mailing Address - Country:US
Mailing Address - Phone:703-830-6380
Mailing Address - Fax:703-263-2441
Practice Address - Street 1:3910 CENTREVILLE RD
Practice Address - Street 2:#100
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-3279
Practice Address - Country:US
Practice Address - Phone:703-830-6380
Practice Address - Fax:703-263-2441
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
VA0618000697152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management