Healthcare Provider Details

I. General information

NPI: 1164943312
Provider Name (Legal Business Name): VARUN KHEDEKAR OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2017
Last Update Date: 07/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 BAY PINES BLVD BUILDING 106
BAY PINES FL
33744-3374
US

IV. Provider business mailing address

11 CORTLAND DR
STOW MA
01775-1053
US

V. Phone/Fax

Practice location:
  • Phone: 727-398-6661
  • Fax:
Mailing address:
  • Phone: 774-258-0377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5225
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOEG003298
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: