Provider Demographics
NPI:1619948015
Name:SCUDDER, GARY E (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:SCUDDER
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 1:4932 KIRBY RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47025-8227
Mailing Address - Country:US
Mailing Address - Phone:125-844-5638
Mailing Address - Fax:
Practice Address - Street 1:4932 KIRBY RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:IN
Practice Address - Zip Code:47025-8227
Practice Address - Country:US
Practice Address - Phone:812-584-4563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021383207Q00000X
IN01021383A208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100093380BMedicaid
IN100093380BMedicaid
INB28507Medicare UPIN