Provider Demographics
NPI:1174574024
Name:KODNER, CHARLES MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:MATTHEW
Last Name:KODNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:7430 JEFFERSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-6159
Practice Address - Country:US
Practice Address - Phone:502-969-0975
Practice Address - Fax:502-969-0975
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64331705Medicaid
IN200150360Medicaid
KY0766116Medicare PIN
IN200150360Medicaid
KY0631225Medicare PIN
KY0523965Medicare PIN
KYG54271Medicare UPIN
KY01174005Medicare PIN
KY0048430Medicare PIN