Provider Demographics
NPI:1497440077
Name:DUDLEY, PHILLIP
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:DUDLEY
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 1:22 ABBEY LN UNIT 2504
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5236
Mailing Address - Country:US
Mailing Address - Phone:413-265-0320
Mailing Address - Fax:
Practice Address - Street 1:100 WOODS RD
Practice Address - Street 2:
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1530
Practice Address - Country:US
Practice Address - Phone:914-493-7692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty