Provider Demographics
NPI:1386776987
Name:WUDEL, ROBERT L (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:L
Last Name:WUDEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:330 N STATE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:DESLOGE
Mailing Address - State:MO
Mailing Address - Zip Code:63601-3052
Mailing Address - Country:US
Mailing Address - Phone:573-431-2829
Mailing Address - Fax:573-431-7186
Practice Address - Street 1:330 N STATE ST
Practice Address - Street 2:SUITE C
Practice Address - City:DESLOGE
Practice Address - State:MO
Practice Address - Zip Code:63601-3052
Practice Address - Country:US
Practice Address - Phone:573-431-2829
Practice Address - Fax:573-431-7186
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO108029207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOD25707Medicare UPIN