Provider Demographics
NPI:1124141379
Name:FUDGE, MELINDA T (MD)
Entity type:Individual
Prefix:
First Name:MELINDA
Middle Name:T
Last Name:FUDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:261 OLD YORK RD
Mailing Address - Street 2:SUITE 634
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-3706
Mailing Address - Country:US
Mailing Address - Phone:215-887-9612
Mailing Address - Fax:215-887-9613
Practice Address - Street 1:261 OLD YORK RD
Practice Address - Street 2:SUITE 634
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3706
Practice Address - Country:US
Practice Address - Phone:215-887-9612
Practice Address - Fax:215-887-9613
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-0477422084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F45730Medicare UPIN
FU429994Medicare ID - Type Unspecified