Provider Demographics
NPI:1073743316
Name:MCDANIEL, DUDLEY DEMAREE (MD)
Entity type:Individual
Prefix:DR
First Name:DUDLEY
Middle Name:DEMAREE
Last Name:MCDANIEL
Suffix:
Gender:M
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 1155
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN PUEBLO
Mailing Address - State:NM
Mailing Address - Zip Code:87566-1155
Mailing Address - Country:US
Mailing Address - Phone:505-747-8711
Mailing Address - Fax:
Practice Address - Street 1:34020 US HIGHWAY 285
Practice Address - Street 2:C/O RANCHO DE SAN JUAN
Practice Address - City:OJO CALINETE
Practice Address - State:NM
Practice Address - Zip Code:87549
Practice Address - Country:US
Practice Address - Phone:505-747-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2005-0573207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology