Provider Demographics
NPI:1528220803
Name:DAVID KUDROW MD
Entity Type:Organization
Organization Name:DAVID KUDROW MD
Other - Org Name:CALIFORNIA MEDICAL CLINIC FOR HEADACHE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:KUDROW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-315-1456
Mailing Address - Street 1:2001 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE #880W
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2102
Mailing Address - Country:US
Mailing Address - Phone:310-315-1456
Mailing Address - Fax:310-315-1486
Practice Address - Street 1:2001 SANTA MONICA BLVD
Practice Address - Street 2:SUITE #880W
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2102
Practice Address - Country:US
Practice Address - Phone:310-315-1456
Practice Address - Fax:310-315-1486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0621662084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW14252AMedicare PIN
CAE70496Medicare UPIN