Provider Demographics
NPI:1740630730
Name:HVEZDA, CARRIE KAY (OD)
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:KAY
Last Name:HVEZDA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:CARRIE
Other - Middle Name:KAY
Other - Last Name:CHRISTOPHERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:5555 WISSAHICKON AVE
Mailing Address - Street 2:APT 304F
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4555
Mailing Address - Country:US
Mailing Address - Phone:612-644-1894
Mailing Address - Fax:
Practice Address - Street 1:3900 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4551
Practice Address - Country:US
Practice Address - Phone:612-644-1894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG003202152W00000X
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program