Provider Demographics
NPI:1588687024
Name:DUDETSKY, ALEXANDER P (MD, PH,D)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:P
Last Name:DUDETSKY
Suffix:
Gender:M
Credentials:MD, PH,D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15710 NE 24TH STREET
Mailing Address - Street 2:STE C
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-2444
Mailing Address - Country:US
Mailing Address - Phone:425-208-0026
Mailing Address - Fax:425-644-3868
Practice Address - Street 1:15710 NE 24TH STREET
Practice Address - Street 2:SUITE C
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-2444
Practice Address - Country:US
Practice Address - Phone:425-208-0026
Practice Address - Fax:425-644-3868
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00045027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8431082Medicaid
WA0199258OtherL&I
WA0199258OtherL&I
WAI1400Medicare UPIN