Provider Demographics
NPI:1013123165
Name:UDALL, DAVID B (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:UDALL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2101 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JUNCTION
Mailing Address - State:TX
Mailing Address - Zip Code:76849-3024
Mailing Address - Country:US
Mailing Address - Phone:325-446-3305
Mailing Address - Fax:325-446-2257
Practice Address - Street 1:109 REID RD
Practice Address - Street 2:
Practice Address - City:JUNCTION
Practice Address - State:TX
Practice Address - Zip Code:76849-3008
Practice Address - Country:US
Practice Address - Phone:325-446-3305
Practice Address - Fax:325-446-2257
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO45537207Q00000X
TXM4971207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COUD45537OtherBLUE CROSS
COC810549Medicare UPIN