Basic Information
Provider Information | |||||||||
NPI: | 1366467607 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KUNDRAT | ||||||||
FirstName: | ANDREW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5730 EXECUTIVE DR STE 230 | ||||||||
Address2: |   | ||||||||
City: | CATONSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 212281762 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4104022379 | ||||||||
FaxNumber: | 4104693085 | ||||||||
Practice Location | |||||||||
Address1: | 3110 GRACEFIELD RD | ||||||||
Address2: |   | ||||||||
City: | SILVER SPRING | ||||||||
State: | MD | ||||||||
PostalCode: | 209041820 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3015728340 | ||||||||
FaxNumber: | 3015728403 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/13/2006 | ||||||||
LastUpdateDate: | 03/04/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/04/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | D0036716 | MD | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
ID | Type | State | Issuer | Description | 9680-0060 | 01 |   | CAREFIRST BCBS OF DC | OTHER | 209821100 | 05 | MD |   | MEDICAID | 04-58254 | 01 |   | EVERCARE | OTHER | 522888-03 | 01 |   | CAREFIRST BCBS OF MD | OTHER | 522096682004 | 01 |   | TRICARE | OTHER |