Provider Demographics
NPI:1083025944
Name:DUDLEY, JOHN MICHAEL (RD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6856 COBBLESTONE BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9311
Mailing Address - Country:US
Mailing Address - Phone:888-416-0008
Mailing Address - Fax:888-416-0009
Practice Address - Street 1:6856 COBBLESTONE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9311
Practice Address - Country:US
Practice Address - Phone:888-416-0008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered