Provider Demographics
NPI:1922541176
Name:MUDD, DENNIS IRVINE III (PA-C)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:IRVINE
Last Name:MUDD
Suffix:III
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2130 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-1442
Mailing Address - Country:US
Mailing Address - Phone:708-768-1507
Mailing Address - Fax:
Practice Address - Street 1:2130 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-1442
Practice Address - Country:US
Practice Address - Phone:708-768-1507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant