Provider Demographics
NPI:1346528114
Name:KUDRICK, NECLA (MD)
Entity Type:Individual
Prefix:
First Name:NECLA
Middle Name:
Last Name:KUDRICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 NUTMEG DR
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06831-3211
Mailing Address - Country:US
Mailing Address - Phone:718-690-0439
Mailing Address - Fax:
Practice Address - Street 1:100 CHURCH ST S STE F206
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1703
Practice Address - Country:US
Practice Address - Phone:203-785-3141
Practice Address - Fax:203-785-2510
Is Sole Proprietor?:No
Enumeration Date:2011-07-28
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2764952080N0001X
CTCT470082080N0001X
PAMD4564622080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03380178Medicaid
PA1031318040001Medicaid
NYA400056573OtherMEDICARE PTAN
PA547875PZPOtherMEDICARE