Provider Demographics
NPI:1073812731
Name:HUMPHREY, TRICIA DUDEK (MD)
Entity Type:Individual
Prefix:
First Name:TRICIA
Middle Name:DUDEK
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1483 TOBIAS GADSON BLVD STE 109
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4795
Mailing Address - Country:US
Mailing Address - Phone:843-556-8110
Mailing Address - Fax:843-556-8112
Practice Address - Street 1:1483 TOBIAS GADSON BLVD STE 109
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4795
Practice Address - Country:US
Practice Address - Phone:843-556-8110
Practice Address - Fax:843-556-8112
Is Sole Proprietor?:No
Enumeration Date:2011-03-21
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP7427208000000X
SC40152208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC401522Medicaid