Provider Demographics
NPI:1740621424
Name:SIDER, KATIE JO (OD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:SIDER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:JO
Other - Last Name:TEMPAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:6881 S YOSEMITE ST
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-1406
Practice Address - Country:US
Practice Address - Phone:303-393-8378
Practice Address - Fax:720-872-4902
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.003297152W00000X
PAOEG002820152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102877001Medicaid
PA102877001Medicaid