Healthcare Provider Details

I. General information

NPI: 1205192077
Provider Name (Legal Business Name): JASON KUDUROGIANIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MAYLAND DR # 8218
RICHMOND VA
23294-4648
US

IV. Provider business mailing address

8401 MAYLAND DR # 8218
RICHMOND VA
23294-4648
US

V. Phone/Fax

Practice location:
  • Phone: 804-603-9163
  • Fax: 619-326-3907
Mailing address:
  • Phone: 804-603-9163
  • Fax: 619-326-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102204869
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: