Provider Demographics
NPI:1154487700
Name:DUDIK, RANDALL G (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:G
Last Name:DUDIK
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1100 W 10TH ST
Practice Address - Street 2:SUITE 160
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2937
Practice Address - Country:US
Practice Address - Phone:573-341-3043
Practice Address - Fax:573-341-5208
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7G68207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208534107Medicaid
MOB22383Medicare UPIN
MO918223230Medicare PIN