Provider Demographics
NPI:1629337324
Name:HUDDLESTON, MARY KATHRYN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY KATHRYN
Middle Name:
Last Name:HUDDLESTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARYKATHRYN
Other - Middle Name:HUDDLESTON
Other - Last Name:COLBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3000 COLISEUM DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-5963
Mailing Address - Country:US
Mailing Address - Phone:757-736-7250
Mailing Address - Fax:757-224-2198
Practice Address - Street 1:3000 COLISEUM DR STE 200
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-736-7250
Practice Address - Fax:757-224-2198
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-15
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012696082086S0129X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program