Provider Demographics
NPI:1518961556
Name:DUDENHOEFER, BRIAN D (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:DUDENHOEFER
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 1:2393 SCHUST RD
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-1334
Mailing Address - Country:US
Mailing Address - Phone:989-793-2820
Mailing Address - Fax:989-755-1463
Practice Address - Street 1:2393 SCHUST RD
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48603-1334
Practice Address - Country:US
Practice Address - Phone:989-793-2820
Practice Address - Fax:989-755-1463
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301093544207W00000X
OH35.087242207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1518961556Medicaid
OH2621158Medicaid
OH2447481OtherUNITED HEALTH CARE
OH35-087242OtherOHIO LICENSE
OH412029328027OtherCARESOURCE
OH7147560OtherAETNA
MI180B910450OtherBLUE CROSS
OH04915OtherPARAMOUNT
MI180B910450OtherBCN
MI1518961556Medicaid
OH$$$$$$$$$003OtherMEDICAL MUTUAL OF OHIO
OH$$$$$$$$$004OtherMEDICAL MUTUAL OF OHIO
OH$$$$$$$$$005OtherMEDICAL MUTUAL OF OHIO
MI1518961556Medicaid
OH7147560OtherAETNA
OH04915OtherPARAMOUNT
OH35-087242OtherOHIO LICENSE
MI0M96170015Medicare PIN
OH4177315Medicare PIN
OH2447481OtherUNITED HEALTH CARE
MI180B910450OtherBCN
OH$$$$$$$$$005OtherMEDICAL MUTUAL OF OHIO
OH4177314Medicare PIN
MI180B910450OtherBLUE CROSS