Provider Demographics
NPI:1295725349
Name:KUDELKO, KENNETH MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:MICHAEL
Last Name:KUDELKO
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 1:7500 HANOVER PKWY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-2010
Mailing Address - Country:US
Mailing Address - Phone:202-365-3284
Mailing Address - Fax:
Practice Address - Street 1:7500 HANOVER PKWY
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-2010
Practice Address - Country:US
Practice Address - Phone:301-982-7944
Practice Address - Fax:301-441-8696
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD584072084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD002848291001OtherUNITED HEALTHCARE
MD9874006OtherCIGNA
MD912931600Medicaid
DC16540021OtherCAREFIRST BCBS
MD941847OtherNCPPO
9232080OtherAETNA
9232080OtherAETNA
MD176517ZGC4Medicare PIN