Provider Demographics
NPI:1962539163
Name:DUDLEY, DANIEL A (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2904 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-2437
Mailing Address - Country:US
Mailing Address - Phone:269-983-2020
Mailing Address - Fax:269-983-3651
Practice Address - Street 1:2904 DIVISION ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-2437
Practice Address - Country:US
Practice Address - Phone:269-983-2020
Practice Address - Fax:269-983-3651
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002802152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1785860Medicaid
MI900A165160OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI900A165160OtherBLUE CROSS BLUE SHIELD OF MICHIGAN
MI0A17615003Medicare PIN
MI0722790001Medicare NSC