Provider Demographics
NPI:1649761735
Name:RODDA, KEVIN (OD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:RODDA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1291 FORSYTHE AVE APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43201-3261
Mailing Address - Country:US
Mailing Address - Phone:330-317-5516
Mailing Address - Fax:
Practice Address - Street 1:368 S HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-3350
Practice Address - Country:US
Practice Address - Phone:614-478-7474
Practice Address - Fax:614-478-7474
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2023-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3556152W00000X
OH6661152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist