Healthcare Provider Details

I. General information

NPI: 1306887757
Provider Name (Legal Business Name): NATHAN KUDRICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 03/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868-3201
US

IV. Provider business mailing address

653 MANHATTAN BEACH BLVD UNIT G
MANHATTAN BEACH CA
90266-4883
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8068
  • Fax: 714-456-3765
Mailing address:
  • Phone: 267-977-7760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA86674
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: