Provider Demographics
NPI:1962606293
Name:DUDLEY, JAMES (ATC LICENSED)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:ATC LICENSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:94 EAGLE LOOP DRIVE
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:OK
Mailing Address - Zip Code:74701-0609
Mailing Address - Country:US
Mailing Address - Phone:580-924-2124
Mailing Address - Fax:580-745-7493
Practice Address - Street 1:1405 N 4TH AVE
Practice Address - Street 2:PMB 4166
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3330
Practice Address - Country:US
Practice Address - Phone:580-745-3028
Practice Address - Fax:580-745-7493
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4142255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer