Provider Demographics
NPI:1801009782
Name:FUDGE, ELIZABETH B (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:B
Last Name:FUDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 918025
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-8025
Mailing Address - Country:US
Mailing Address - Phone:352-334-1390
Mailing Address - Fax:352-334-1325
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3003
Practice Address - Country:US
Practice Address - Phone:352-334-1390
Practice Address - Fax:352-334-1325
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-012462080P0205X
FLME1083152080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002840300Medicaid
FL002840300Medicaid
FLED037ZMedicare PIN