Provider Demographics
NPI:1689651606
Name:DUDLEY, CAROLYN GAIL (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:GAIL
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 MOUNT VERNON HWY NE
Mailing Address - Street 2:STE 310
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4288
Mailing Address - Country:US
Mailing Address - Phone:952-595-1301
Mailing Address - Fax:612-294-4903
Practice Address - Street 1:755 MOUNT VERNON HWY NE STE 310
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4288
Practice Address - Country:US
Practice Address - Phone:952-595-1100
Practice Address - Fax:612-294-4903
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-30
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2898192085R0202X
GA0287622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADC7006OtherGA RR
GA30BDDXKMedicare ID - Type Unspecified
AL009939932Medicaid
GA198454OtherBCBS
GAP00353197OtherRAILROAD MEDICARE
GAE46998Medicare UPIN
GA000436752EMedicaid