Provider Demographics
NPI:1962583047
Name:FUDGE, MARY L (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:L
Last Name:FUDGE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:F
Other - Last Name:FANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-2503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:789 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820-2526
Practice Address - Country:US
Practice Address - Phone:603-749-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH14621208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3074322Medicaid