Provider Demographics
NPI:1356317184
Name:FUDALA, STANLEY (MD)
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:
Last Name:FUDALA
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 1:500 MCMILLEN ST
Mailing Address - Street 2:FORT HEALTHCARE
Mailing Address - City:FORT ATKINSON
Mailing Address - State:WI
Mailing Address - Zip Code:53538-1233
Mailing Address - Country:US
Mailing Address - Phone:920-563-5571
Mailing Address - Fax:920-563-4228
Practice Address - Street 1:500 MCMILLEN STREET
Practice Address - Street 2:
Practice Address - City:FORT ATKINSON
Practice Address - State:WI
Practice Address - Zip Code:53538-1263
Practice Address - Country:US
Practice Address - Phone:950-563-5571
Practice Address - Fax:920-563-4228
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41002-202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34449000Medicaid
WI84767Medicare PIN
WII05343Medicare UPIN