Healthcare Provider Details

I. General information

NPI: 1295725349
Provider Name (Legal Business Name): KENNETH MICHAEL KUDELKO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 06/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 HANOVER PKWY SUITE 201
GREENBELT MD
20770-2010
US

IV. Provider business mailing address

7500 HANOVER PKWY SUITE 201
GREENBELT MD
20770-2010
US

V. Phone/Fax

Practice location:
  • Phone: 301-982-7944
  • Fax: 301-441-8696
Mailing address:
  • Phone: 202-365-3284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberD58407
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: