Provider Demographics
NPI:1972524619
Name:DUDLEY, CALVIN (MD)
Entity Type:Individual
Prefix:
First Name:CALVIN
Middle Name:
Last Name:DUDLEY
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 1:3810 MASTHEAD ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4479
Mailing Address - Country:US
Mailing Address - Phone:505-243-3514
Mailing Address - Fax:505-243-3451
Practice Address - Street 1:3810 MASTHEAD ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4479
Practice Address - Country:US
Practice Address - Phone:505-243-3514
Practice Address - Fax:505-243-3451
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM86-222208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM010744OtherBCBS NEW MEXICO
NM201002646OtherPRESBYTERIAN HEALTH PLAN
NM37689Medicaid
NMC97727Medicare UPIN
NM37689Medicaid