Provider Demographics
NPI:1649282492
Name:HUDOCK, KRISTIN MARA (MD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MARA
Last Name:HUDOCK
Suffix:
Gender:F
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:PO BOX 636256
Mailing Address - Street 2:CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3600
Mailing Address - Fax:513-245-3672
Practice Address - Street 1:231 ALBERT SABIN WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-2827
Practice Address - Country:US
Practice Address - Phone:513-558-0588
Practice Address - Fax:513-558-4858
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35126355207RC0200X, 207RP1001X
PAMD435541207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC019983M65Medicare PIN