Provider Demographics
NPI:1235267394
Name:ANDREA B DUDLEY OD, INC PC
Entity Type:Organization
Organization Name:ANDREA B DUDLEY OD, INC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:BERTALOTTO
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-745-9700
Mailing Address - Street 1:5910 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7112
Mailing Address - Country:US
Mailing Address - Phone:918-745-9700
Mailing Address - Fax:918-743-8102
Practice Address - Street 1:5910 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7112
Practice Address - Country:US
Practice Address - Phone:918-745-9700
Practice Address - Fax:918-743-8102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA0515Medicare PIN