Provider Demographics
NPI:1659330652
Name:ZWIESDAK, KELLY J (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:ZWIESDAK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3320 SILAS CREEK PKWY
Mailing Address - Street 2:SUITE 300
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3031
Mailing Address - Country:US
Mailing Address - Phone:336-760-2169
Mailing Address - Fax:336-760-2385
Practice Address - Street 1:3320 SILAS CREEK PKWY
Practice Address - Street 2:SUITE 300
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3031
Practice Address - Country:US
Practice Address - Phone:336-760-2169
Practice Address - Fax:336-760-2385
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2076152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908843Medicaid
NC2473141Medicare PIN