Provider Demographics
NPI:1821350505
Name:CARODDO, KATHLEEN KERRY (MSED)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:KERRY
Last Name:CARODDO
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DEVON DR
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-1415
Mailing Address - Country:US
Mailing Address - Phone:516-557-8951
Mailing Address - Fax:
Practice Address - Street 1:4 DEVON DR
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-1415
Practice Address - Country:US
Practice Address - Phone:516-557-8951
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY408785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY69377829Medicare PIN