Provider Demographics
NPI:1568510675
Name:FUDEMBERG, SCOTT JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:JACOB
Last Name:FUDEMBERG
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 1:18791 JOHN J WILLIAMS HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-9435
Mailing Address - Country:US
Mailing Address - Phone:302-645-2300
Mailing Address - Fax:
Practice Address - Street 1:18791 JOHN J WILLIAMS HWY STE 1
Practice Address - Street 2:
Practice Address - City:REHOBOTH BEACH
Practice Address - State:DE
Practice Address - Zip Code:19971-9435
Practice Address - Country:US
Practice Address - Phone:302-645-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS6253207W00000X
DEC1-0008886207W00000X
NJ25MA08470400207W00000X
PAMD431150207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology