Healthcare Provider Details

I. General information

NPI: 1275760910
Provider Name (Legal Business Name): KRISTIN DIANE HUDACEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2009
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20730 VALLEY GREEN DR
CUPERTINO CA
95014-1704
US

IV. Provider business mailing address

333 MAIN ST APT 327
REDWOOD CITY CA
94063-1762
US

V. Phone/Fax

Practice location:
  • Phone: 408-783-4000
  • Fax:
Mailing address:
  • Phone: 267-320-9261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA126296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: