Basic Information
| Provider Information | |||||||||
| NPI: | 1356539084 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CUDKOWICZ | ||||||||
| FirstName: | ALEX | ||||||||
| MiddleName: | RAIMES | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 N MILDRED RD | ||||||||
| Address2: | |||||||||
| City: | CORTEZ | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813212435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705658482 | ||||||||
| FaxNumber: | 9705658478 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N MILDRED RD | ||||||||
| Address2: | |||||||||
| City: | CORTEZ | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813212435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9705658482 | ||||||||
| FaxNumber: | 9705658478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2007 | ||||||||
| LastUpdateDate: | 12/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 34477 | CO | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 01344779 | 05 | CO | MEDICAID | Q4652 | 01 | NM | NEW MEXICO MEDICAID | OTHER |