Provider Demographics
NPI:1255381588
Name:DUDA, CHARLES R (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:DUDA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:MARINETTE
Mailing Address - State:WI
Mailing Address - Zip Code:54143-1934
Mailing Address - Country:US
Mailing Address - Phone:715-732-4018
Mailing Address - Fax:715-735-6864
Practice Address - Street 1:3110 GILBERT ST
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-1934
Practice Address - Country:US
Practice Address - Phone:715-732-4018
Practice Address - Fax:715-735-6864
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3119-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI200808401011OtherBCBS GROUP #
WI38999700Medicaid
MI4724161Medicaid
WI38999700Medicaid