Provider Demographics
NPI:1568544773
Name:DUDLEY, ANDREA BERTALOTTO (OD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:BERTALOTTO
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 S LEWIS
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-7112
Mailing Address - Country:US
Mailing Address - Phone:918-745-9700
Mailing Address - Fax:918-743-8102
Practice Address - Street 1:5910 S LEWIS
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-7112
Practice Address - Country:US
Practice Address - Phone:918-745-9700
Practice Address - Fax:918-743-8107
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2215152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKAAA0514Medicare PIN