Provider Demographics
NPI:1336312735
Name:DUDNEY, ELIJAH M
Entity Type:Individual
Prefix:DR
First Name:ELIJAH
Middle Name:M
Last Name:DUDNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:GAINESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38562-0126
Mailing Address - Country:US
Mailing Address - Phone:931-268-9321
Mailing Address - Fax:
Practice Address - Street 1:2546 FREESTATE ROAD
Practice Address - Street 2:
Practice Address - City:GAINESBORO
Practice Address - State:TN
Practice Address - Zip Code:38562-0126
Practice Address - Country:US
Practice Address - Phone:931-268-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-07
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAD1193337208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB01645Medicare UPIN