Provider Demographics
NPI:1205835493
Name:HUDSPETH, DUDLEY A (MD)
Entity Type:Individual
Prefix:
First Name:DUDLEY
Middle Name:A
Last Name:HUDSPETH
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 1:485 S DOBSON RD
Mailing Address - Street 2:STE 111
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-5600
Mailing Address - Country:US
Mailing Address - Phone:480-407-4999
Mailing Address - Fax:480-407-4998
Practice Address - Street 1:485 S DOBSON RD
Practice Address - Street 2:STE 111
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5600
Practice Address - Country:US
Practice Address - Phone:480-407-4999
Practice Address - Fax:480-407-4998
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32737208600000X
AZ23299208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5915635Medicaid
AZ320060Medicaid
AZZ76591OtherGROUP PIN
D93518Medicare UPIN
AZZ76592Medicare PIN
NC2076619Medicare PIN