Healthcare Provider Details

I. General information

NPI: 1609072792
Provider Name (Legal Business Name): KIM N POLUDNIANYK D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2007
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD FL 3
LAKE CHARLES LA
70601
US

IV. Provider business mailing address

PO BOX 122165 DEPT 2165
DALLAS TX
75312-2165
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-4900
  • Fax: 337-494-4936
Mailing address:
  • Phone: 337-494-4900
  • Fax: 337-494-4936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number320010
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: