Provider Demographics
NPI:1558324145
Name:NUDLEMAN, KENNETH LEONARD (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEONARD
Last Name:NUDLEMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4790 IRVINE BLVD.
Mailing Address - Street 2:SUITE 105 PMB 241
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92620-1998
Mailing Address - Country:US
Mailing Address - Phone:714-542-7996
Mailing Address - Fax:714-542-3011
Practice Address - Street 1:801 N. TUSTIN AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3601
Practice Address - Country:US
Practice Address - Phone:714-542-7996
Practice Address - Fax:714-542-3011
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG374072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G374070Medicaid
CAA47070Medicare UPIN
CA00G374070Medicaid