Provider Demographics
NPI:1700926037
Name:KLEDARAS, GEORGE W (OD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:W
Last Name:KLEDARAS
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 1:230 PHILADELPHIA PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-3125
Mailing Address - Country:US
Mailing Address - Phone:302-764-4613
Mailing Address - Fax:302-764-3201
Practice Address - Street 1:230 PHILADELPHIA PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19809-3125
Practice Address - Country:US
Practice Address - Phone:302-764-4613
Practice Address - Fax:302-764-3201
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEI30001166152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000172422Medicaid
DE173454Medicare UPIN
DET73254Medicare UPIN