Provider Demographics
NPI:1194760579
Name:KUNDRAT, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:KUNDRAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4819
Mailing Address - Fax:860-358-4809
Practice Address - Street 1:4 GROVE BEACH RD NORTH
Practice Address - Street 2:BUILDING 1, UNIT A
Practice Address - City:WESTBROOK
Practice Address - State:CT
Practice Address - Zip Code:06498
Practice Address - Country:US
Practice Address - Phone:860-664-3553
Practice Address - Fax:860-664-3756
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT018585207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1185859Medicaid
CT080001581Medicare PIN
CTB37922Medicare UPIN