Provider Demographics
NPI:1740704857
Name:GUDORF, BENJAMIN KEITH (CNP)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KEITH
Last Name:GUDORF
Suffix:
Gender:
Credentials:CNP
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 7527
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-0727
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:OH
Practice Address - Zip Code:45882-9228
Practice Address - Country:US
Practice Address - Phone:419-363-3008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-31
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021214363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily