Provider Demographics
NPI:1497167795
Name:DUDZIC, JOHN (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DUDZIC
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5736 N YALE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97203-5663
Mailing Address - Country:US
Mailing Address - Phone:315-383-0606
Mailing Address - Fax:
Practice Address - Street 1:2064 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-4439
Practice Address - Country:US
Practice Address - Phone:503-719-7742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR20372225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist