Provider Demographics
NPI:1093716375
Name:KUDISCH, MARC L (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:KUDISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 S GESSNER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-3770
Mailing Address - Country:US
Mailing Address - Phone:713-777-9995
Mailing Address - Fax:713-777-0100
Practice Address - Street 1:3030 S GESSNER RD STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-3770
Practice Address - Country:US
Practice Address - Phone:713-777-9995
Practice Address - Fax:713-777-0100
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ1289207RG0100X
CODR.0065485207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131866903Medicaid
TX00R49GMedicare ID - Type Unspecified
TX131866903Medicaid