Provider Demographics
NPI:1023074853
Name:BUDZAK, MARY L (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:BUDZAK
Suffix:
Gender:F
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:PO BOX 1144
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45401-1144
Mailing Address - Country:US
Mailing Address - Phone:937-259-9900
Mailing Address - Fax:937-259-9999
Practice Address - Street 1:1001 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1600
Practice Address - Country:US
Practice Address - Phone:937-767-7369
Practice Address - Fax:937-767-7703
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35048312207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0102990Medicaid
0774713Medicare PIN
D15466Medicare UPIN