Provider Demographics
NPI:1689784019
Name:DUDLEY, MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2505 E 3300 S
Mailing Address - Street 2:STE 201
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2764
Mailing Address - Country:US
Mailing Address - Phone:801-359-3995
Mailing Address - Fax:801-359-8489
Practice Address - Street 1:1053 E 2100 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2349
Practice Address - Country:US
Practice Address - Phone:801-359-3995
Practice Address - Fax:801-359-8489
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT286024-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU98562Medicare UPIN
UT000057522Medicare ID - Type Unspecified