Healthcare Provider Details

I. General information

NPI: 1164805099
Provider Name (Legal Business Name): KRYSTYN KUDLA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

35776 HARPER AVE
CLINTON TOWNSHIP MI
48035-3212
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax:
Mailing address:
  • Phone: 586-792-3891
  • Fax: 586-792-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901004896
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: