Provider Demographics
NPI:1790710952
Name:DUDEK, STEPHEN L (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:L
Last Name:DUDEK
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:PO BOX 1450
Mailing Address - Street 2:
Mailing Address - City:MANITOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:54221-1450
Mailing Address - Country:US
Mailing Address - Phone:920-684-5560
Mailing Address - Fax:
Practice Address - Street 1:2300 WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54221-1450
Practice Address - Country:US
Practice Address - Phone:920-684-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0248232085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30769100Medicaid
B84811Medicare UPIN
WI0003Medicare ID - Type Unspecified