Provider Demographics
NPI:1245399112
Name:KOKICH, RUDY E (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDY
Middle Name:E
Last Name:KOKICH
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 1:104 FAIRVIEW DRIVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851
Mailing Address - Country:US
Mailing Address - Phone:757-562-5121
Mailing Address - Fax:
Practice Address - Street 1:104 FAIRVIEW DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851
Practice Address - Country:US
Practice Address - Phone:757-562-5121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101040305174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA045498OtherANTHEM
NC890542EMedicaid
VA045498OtherANTHEM