Healthcare Provider Details

I. General information

NPI: 1043180227
Provider Name (Legal Business Name): MATHEW ALLAN CHRISTOPHER KUDYM SR. LORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 11/11/2025
Certification Date: 11/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9635 MOCKINGBIRD DR APT 16
OMAHA NE
68127-2039
US

IV. Provider business mailing address

9635 MOCKINGBIRD DR APT 16
OMAHA NE
68127-2039
US

V. Phone/Fax

Practice location:
  • Phone: 402-216-2966
  • Fax:
Mailing address:
  • Phone: 402-216-2966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberH12713341
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: