Provider Demographics
NPI:1770553364
Name:KUDERKO, JOSEPH M (MD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:M
Last Name:KUDERKO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3098
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3098
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:20911 EARL ST STE 470
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4355
Practice Address - Country:US
Practice Address - Phone:310-372-0700
Practice Address - Fax:310-372-0774
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG152916207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN907385000Medicaid
MN040000045Medicare ID - Type UnspecifiedMEDICARE
MN907385000Medicaid