Healthcare Provider Details

I. General information

NPI: 1639551054
Provider Name (Legal Business Name): VISHAL KUDAV
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2015
Last Update Date: 10/01/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOSPITAL DR MCHANEY HALL 404
COLUMBIA MO
65212-1000
US

IV. Provider business mailing address

6431 FANNIN STREET MSB 4.156
HOUSTON TX
77030-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-884-2000
  • Fax:
Mailing address:
  • Phone: 713-500-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015018173
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: