Provider Demographics
NPI:1831483585
Name:TADDIE, KRISTEN JEAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:JEAN
Last Name:TADDIE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 W TAFT RD
Mailing Address - Street 2:STE 4M
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3810
Mailing Address - Country:US
Mailing Address - Phone:315-455-5500
Mailing Address - Fax:
Practice Address - Street 1:125 LAWRENCE RD E
Practice Address - Street 2:
Practice Address - City:N SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3844
Practice Address - Country:US
Practice Address - Phone:315-455-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-29
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007736152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist