Healthcare Provider Details

I. General information

NPI: 1376500975
Provider Name (Legal Business Name): JOHN KUDRYK O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14775 FEATHER COVE RD
CLEARWATER FL
33762-3018
US

IV. Provider business mailing address

14775 FEATHER COVE RD
CLEARWATER FL
33762-3018
US

V. Phone/Fax

Practice location:
  • Phone: 813-731-3276
  • Fax:
Mailing address:
  • Phone: 813-731-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: