Provider Demographics
NPI:1013067578
Name:VARNER E. DUDLEY, III, M.D., INC
Entity Type:Organization
Organization Name:VARNER E. DUDLEY, III, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VARNER
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:626-584-1556
Mailing Address - Street 1:225 S LAKE AVE
Mailing Address - Street 2:SUITE 535
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-3005
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:626-795-8247
Practice Address - Street 1:1509 WILSON TER
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4007
Practice Address - Country:US
Practice Address - Phone:818-409-8000
Practice Address - Fax:818-546-5632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55075207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G550750OtherBLUE SHIELD
CA00G550750Medicaid
CA00G550750OtherBLUE SHIELD
CA00G550750Medicaid