Provider Demographics
NPI:1790937712
Name:FRED AND LINDA KODESCH, MDS
Entity Type:Organization
Organization Name:FRED AND LINDA KODESCH, MDS
Other - Org Name:KODESCH AND KODESCH, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:KODESCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-267-2001
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME49057207K00000X
FLME49056207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044369700Medicaid
FL044227500Medicaid
FL044227500Medicaid
A24614Medicare UPIN
02198Medicare PIN
02199Medicare PIN