Provider Demographics
NPI:1881644722
Name:MUDD, KEVIN J (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:MUDD
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 1:262 BANK ST
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-1537
Mailing Address - Country:US
Mailing Address - Phone:585-344-3050
Mailing Address - Fax:585-344-3043
Practice Address - Street 1:262 BANK ST
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1537
Practice Address - Country:US
Practice Address - Phone:585-344-3050
Practice Address - Fax:585-344-3043
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198795174400000X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY35459AOtherMEDICARE GROUP PTAN
NY01685405Medicaid
NYJ400177728Medicare PIN