Provider Demographics
NPI:1326172149
Name:TUDOR, MARK ALAN (LAT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:TUDOR
Suffix:
Gender:M
Credentials:LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 ALONGI LN
Mailing Address - Street 2:STE M
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-2393
Mailing Address - Country:US
Mailing Address - Phone:608-365-8660
Mailing Address - Fax:
Practice Address - Street 1:1650 LEE LN
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-3935
Practice Address - Country:US
Practice Address - Phone:608-365-8660
Practice Address - Fax:608-365-6342
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI334-0392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer