Provider Demographics
NPI:1407820178
Name:KODESCH, FRED (MD)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:KODESCH
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 1:4300 GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32796-2937
Mailing Address - Country:US
Mailing Address - Phone:321-267-2001
Mailing Address - Fax:321-267-0628
Practice Address - Street 1:4300 GARDEN ST
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32796-2937
Practice Address - Country:US
Practice Address - Phone:321-267-2001
Practice Address - Fax:321-267-0628
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0049056207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLA24614Medicare UPIN
FL02199Medicare ID - Type Unspecified