Provider Demographics
NPI:1295806248
Name:KOLUDROVICH, BRIAN ANDREW (DPM)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:ANDREW
Last Name:KOLUDROVICH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35010 CHARDON RD STE 101A
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9011
Mailing Address - Country:US
Mailing Address - Phone:440-953-3668
Mailing Address - Fax:440-953-3556
Practice Address - Street 1:35010 CHARDON RD STE 101A
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9011
Practice Address - Country:US
Practice Address - Phone:440-953-3668
Practice Address - Fax:440-953-3556
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36002432213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0752270Medicaid
OH0752270Medicaid