Provider Demographics
NPI:1295833630
Name:DUDNICK, ROBERT S (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:DUDNICK
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 1:5401 OLD YORK RD
Mailing Address - Street 2:KLEIN, SUITE 202
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3030
Mailing Address - Country:US
Mailing Address - Phone:215-456-8210
Mailing Address - Fax:215-329-1085
Practice Address - Street 1:5401 OLD YORK RD
Practice Address - Street 2:KLEIN, SUITE 202
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3030
Practice Address - Country:US
Practice Address - Phone:215-456-8210
Practice Address - Fax:215-329-1085
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD045109E207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA05154105001Medicaid
PA05154105001Medicaid