Provider Demographics
NPI:1932126489
Name:DUDLEY, JAMES ROANE (MD, MBA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ROANE
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:RIVERSIDE MEDICAL GROUP
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:
Practice Address - Street 1:618 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TAPPAHANNOCK
Practice Address - State:VA
Practice Address - Zip Code:22560-5000
Practice Address - Country:US
Practice Address - Phone:804-443-8649
Practice Address - Fax:804-443-6150
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-039671207P00000X
VA0101039671207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B05190Medicare UPIN
P00406618Medicare PIN
VA080008217Medicare PIN
013768R71Medicare PIN
VA080007005Medicare PIN
VA005626854Medicaid
VA930001192Medicare PIN
VA005626692Medicaid
B05190Medicare UPIN
VA080008218Medicare PIN
VA080008219Medicare PIN
VA080008216Medicare PIN
VA005619025Medicaid
VA005639166Medicaid