Healthcare Provider Details

I. General information

NPI: 1508770363
Provider Name (Legal Business Name): DAVID KUDLIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12735 W CAPITOL DR
BROOKFIELD WI
53005-2442
US

IV. Provider business mailing address

6640 ROMA WAY
NAPLES FL
34113-1721
US

V. Phone/Fax

Practice location:
  • Phone: 262-783-7302
  • Fax:
Mailing address:
  • Phone: 262-783-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number11080-40
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: