Healthcare Provider Details

I. General information

NPI: 1023064847
Provider Name (Legal Business Name): JOHN J KUDLAK JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PATEWOOD DR SUITE B300
GREENVILLE SC
29615-3593
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-454-4200
  • Fax: 864-454-4205
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number714
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: