Healthcare Provider Details

I. General information

NPI: 1952407488
Provider Name (Legal Business Name): DAVID BRUCE KUDROW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 SANTA MONICA BLVD SUITE 880W
SANTA MONCIA CA
90404-2102
US

IV. Provider business mailing address

2001 SANTA MONICA BLVD SUITE 880W
SANTA MONICA CA
90404-2102
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-1456
  • Fax: 310-315-1486
Mailing address:
  • Phone: 310-315-1456
  • Fax: 310-315-1486

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG62166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: