Provider Demographics
NPI:1447217260
Name:WILEY, DUDLEY EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:DUDLEY
Middle Name:EUGENE
Last Name:WILEY
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 1:6968 PINES LN SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-9095
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6968 PINES LN SE
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MI
Practice Address - Zip Code:49316-9095
Practice Address - Country:US
Practice Address - Phone:616-891-9601
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010350952084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447217260Medicaid
MI1220582Medicaid
MIDW035095OtherBCBS MI STATE LIC NUMBER
MI350D176500OtherBCBS GROUP
MI130D113740OtherBCBS OF MI GROUP NUMBER
MI1220582Medicaid
MIDW035095OtherBCBS MI STATE LIC NUMBER
MIA76032Medicare UPIN