Provider Demographics
NPI:1891982039
Name:FUDGE, ROBERT PAUL
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:PAUL
Last Name:FUDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:ROOM 368 DOAN HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-293-3358
Mailing Address - Fax:614-293-7082
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:ROOM 368 DOAN HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-3358
Practice Address - Fax:614-293-7082
Is Sole Proprietor?:No
Enumeration Date:2007-10-02
Last Update Date:2007-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03-3-09815183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist