Provider Demographics
NPI:1841362068
Name:KUDLAK, THERESA T (MD)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:T
Last Name:KUDLAK
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 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD13466207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME293410099Medicaid
ME3240685OtherAETNA
AX6983Medicare PIN
MEM101534OtherCIGNA
MEB20272Medicare UPIN
ME050044664Medicare ID - Type UnspecifiedRAILROAD
NH30201134Medicaid
MEMM649401Medicare PIN
MEB20272OtherHPHC
ME018117OtherANTHEM
MEMM4694Medicare ID - Type Unspecified