Provider Demographics
NPI:1710983937
Name:DUDLEY, ROBERT (MD, MED)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:MD, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 LAFAYETTE STREET
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051
Mailing Address - Country:US
Mailing Address - Phone:860-224-3642
Mailing Address - Fax:860-224-2760
Practice Address - Street 1:85 LAFAYETTE STREET
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051
Practice Address - Country:US
Practice Address - Phone:860-224-3642
Practice Address - Fax:860-224-2760
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2013-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008010542Medicaid
CT008010542Medicaid
CT370000996Medicare ID - Type Unspecified