Provider Demographics
NPI:1871674762
Name:KILGORE, CARL JUDSON (MD)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:JUDSON
Last Name:KILGORE
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 1:225 CLIFF PARK RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3148
Mailing Address - Country:US
Mailing Address - Phone:607-272-3390
Mailing Address - Fax:
Practice Address - Street 1:225 CLIFF PARK RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3148
Practice Address - Country:US
Practice Address - Phone:607-272-3390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087197-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00416817Medicaid
CC1536Medicare ID - Type Unspecified
D74937Medicare UPIN