Provider Demographics
NPI:1477580140
Name:DUDEK, GREGORY A (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:DUDEK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 CROCKER BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2505
Mailing Address - Country:US
Mailing Address - Phone:586-465-7422
Mailing Address - Fax:586-465-1480
Practice Address - Street 1:117 CROCKER BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2505
Practice Address - Country:US
Practice Address - Phone:586-465-7422
Practice Address - Fax:586-465-1480
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIGD002916111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2096664Medicaid
MIP42816OtherBLUE CARE NETWORK
MIT33146Medicare UPIN
MI0E05081Medicare ID - Type Unspecified