Provider Demographics
NPI:1881120046
Name:KUDRA, ANTHONY RAY III
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:RAY
Last Name:KUDRA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 BERKSHIRE PLACE
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417
Mailing Address - Country:US
Mailing Address - Phone:708-860-7479
Mailing Address - Fax:
Practice Address - Street 1:860 BERKSHIRE PLACE
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417
Practice Address - Country:US
Practice Address - Phone:708-860-7479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program