Provider Demographics
NPI:1205192077
Name:KUDUROGIANIS, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:KUDUROGIANIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 EISENHOWER AVE STE 220
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4587
Mailing Address - Country:US
Mailing Address - Phone:833-351-8255
Mailing Address - Fax:888-815-3583
Practice Address - Street 1:2800 EISENHOWER AVE STE 220
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4587
Practice Address - Country:US
Practice Address - Phone:833-351-8255
Practice Address - Fax:888-815-3583
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-06
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022048692084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty