Provider Demographics
NPI:1396871125
Name:PAUL L. DUDLEY, M.D., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:PAUL L. DUDLEY, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-497-0027
Mailing Address - Street 1:2220 LYNN RD STE 206
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8007
Mailing Address - Country:US
Mailing Address - Phone:805-497-0027
Mailing Address - Fax:805-497-0147
Practice Address - Street 1:2220 LYNN RD STE 206
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8007
Practice Address - Country:US
Practice Address - Phone:805-497-0027
Practice Address - Fax:805-497-0147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25705174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G257050Medicaid
CAA42763Medicare UPIN
G25705Medicare PIN