Provider Demographics
NPI:1245671932
Name:WEDEKING CALARCO, KASSANDRA M (OD)
Entity type:Individual
Prefix:DR
First Name:KASSANDRA
Middle Name:M
Last Name:WEDEKING CALARCO
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 1:7789 147TH ST W
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-7568
Mailing Address - Country:US
Mailing Address - Phone:952-432-0680
Mailing Address - Fax:952-432-8823
Practice Address - Street 1:7789 147TH ST W
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124
Practice Address - Country:US
Practice Address - Phone:952-432-0680
Practice Address - Fax:952-432-8823
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3550152W00000X
CT2889152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008051554Medicaid