Provider Demographics
NPI:1619065729
Name:DUDASH, JOHN A (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:DUDASH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 MAIN STREET PO BOX 430
Mailing Address - Street 2:
Mailing Address - City:NEW EAGLE
Mailing Address - State:PA
Mailing Address - Zip Code:15067
Mailing Address - Country:US
Mailing Address - Phone:724-258-3773
Mailing Address - Fax:724-258-4805
Practice Address - Street 1:120 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NEW EAGLE
Practice Address - State:PA
Practice Address - Zip Code:15067
Practice Address - Country:US
Practice Address - Phone:724-258-3773
Practice Address - Fax:724-258-4805
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0E004668P152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01746334Medicaid
PA01746334Medicaid
00190449Medicare ID - Type Unspecified