Provider Demographics
NPI:1639105034
Name:TUDTUD, NENITA C (MD)
Entity Type:Individual
Prefix:DR
First Name:NENITA
Middle Name:C
Last Name:TUDTUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NENITA
Other - Middle Name:C
Other - Last Name:TUDTUD-JHEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1015 S MERCER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-7107
Mailing Address - Country:US
Mailing Address - Phone:309-662-7500
Mailing Address - Fax:309-662-7333
Practice Address - Street 1:1015 S MERCER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-7107
Practice Address - Country:US
Practice Address - Phone:309-662-7500
Practice Address - Fax:309-662-7333
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-052568208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA2264OtherRR MEDICARE GROUP #
IL833120OtherMEDICARE GROUP #
IL036052568Medicaid
P00706576OtherRR INDIVIDUAL #
K20978Medicare ID - Type Unspecified
D13388Medicare UPIN
P00706576OtherRR INDIVIDUAL #