Provider Demographics
NPI:1275630568
Name:DUDZIAK, DONNA E (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:E
Last Name:DUDZIAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:E
Other - Last Name:FRANCIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:901 SAN BERNARDINO RD
Mailing Address - Street 2:STE 301
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4912
Mailing Address - Country:US
Mailing Address - Phone:909-946-6221
Mailing Address - Fax:909-949-3802
Practice Address - Street 1:901 SAN BERNARDINO RD
Practice Address - Street 2:STE 301
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4912
Practice Address - Country:US
Practice Address - Phone:909-946-6221
Practice Address - Fax:909-949-3802
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87866208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC207WMedicare PIN
CADC207YMedicare PIN