Provider Demographics
NPI:1225191885
Name:BADRUDDUJA, SYED G (MD)
Entity type:Individual
Prefix:DR
First Name:SYED
Middle Name:G
Last Name:BADRUDDUJA
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 1:400 UNIVERSITY DR STE 203
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-1080
Mailing Address - Country:US
Mailing Address - Phone:606-886-8183
Mailing Address - Fax:606-886-0575
Practice Address - Street 1:400 UNIVERSITY DR STE 203
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-1080
Practice Address - Country:US
Practice Address - Phone:606-886-8183
Practice Address - Fax:606-886-0575
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY17825208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000057545OtherBLUE CROSS PROVIDER NUMBE
KY65901951Medicaid
KY65901951Medicaid
KY000000057545OtherBLUE CROSS PROVIDER NUMBE