Provider Demographics
NPI:1083951016
Name:KENNETH L. NUDLEMAN, M.D., INC.
Entity Type:Organization
Organization Name:KENNETH L. NUDLEMAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:NUDLEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-542-7996
Mailing Address - Street 1:4790 IRVINE BLVD.
Mailing Address - Street 2:SUITE 105-241
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1998
Mailing Address - Country:US
Mailing Address - Phone:714-542-7996
Mailing Address - Fax:714-542-3011
Practice Address - Street 1:801 N. TUSTIN AVE.
Practice Address - Street 2:SUITE 304
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3608
Practice Address - Country:US
Practice Address - Phone:714-542-7996
Practice Address - Fax:714-542-3011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG374072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G374070Medicaid
CA00G374070Medicaid
CAA47070Medicare UPIN