Provider Demographics
NPI:1922097955
Name:KUDELKO, JENNIFER LYNN (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:KUDELKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13644 WALSINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33774-3532
Mailing Address - Country:US
Mailing Address - Phone:727-595-2519
Mailing Address - Fax:727-595-3872
Practice Address - Street 1:13644 WALSINGHAM RD
Practice Address - Street 2:
Practice Address - City:LARGO
Practice Address - State:FL
Practice Address - Zip Code:33774-3532
Practice Address - Country:US
Practice Address - Phone:727-595-2519
Practice Address - Fax:727-595-3872
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9229207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
591273247OtherUHC EMPIRE PLAN
810603OtherMAIL HANDLERS BENEFIT PLAN (MHBP)
FL2562320OtherUNITED HEALTHCARE COMMERCIAL AND MEDICARE PLANS
FL29502OtherBCBS BLUE CARE, ADVANTAGE 65 SELECT, MEDICARE PPO/HMO, GO BLUE
FL29502OtherOUT OF STATE BLUE CROSS BLUE SHIELD
FL298652OtherAVMED
FL8005755OtherCIGNA PPO/HMO, OPEN ACCESS, AND GREATWEST
FL29502OtherBLUE OPTIONS, BLUE CHOICE, FEDERAL, FLORIDA STATE AND TRADITIONAL BCBS
FL29502OtherBCBS BLUE CARE, ADVANTAGE 65 SELECT, MEDICARE PPO/HMO, GO BLUE
FL298652OtherAVMED
FL8005755OtherCIGNA PPO/HMO, OPEN ACCESS, AND GREATWEST