Provider Demographics
NPI:1366165094
Name:KALLON, JEREDINE M (OD)
Entity type:Individual
Prefix:DR
First Name:JEREDINE
Middle Name:M
Last Name:KALLON
Suffix:
Gender:
Credentials:OD
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Mailing Address - Street 1:PO BOX 208869
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8869
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:14 CONSULTANT PL STE 100
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-6326
Practice Address - Country:US
Practice Address - Phone:919-493-3668
Practice Address - Fax:919-490-5594
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2812152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNA4048BOtherMEDICARE