Provider Demographics
NPI:1992703474
Name:NUDELMAN, JAMES A (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:NUDELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 FAWCETT AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1911
Mailing Address - Country:US
Mailing Address - Phone:253-761-4200
Mailing Address - Fax:253-761-4201
Practice Address - Street 1:1304 FAWCETT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1911
Practice Address - Country:US
Practice Address - Phone:253-761-4200
Practice Address - Fax:253-761-4201
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK18872085R0202X
WAMD000184982085R0202X
ORMD292332085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1052565-01Medicaid
WA2047560Medicaid
OR500694700Medicaid
WAG8944348Medicare PIN
ORR184329Medicare PIN
TX86R795Medicare PIN
WA2047560Medicaid
WAG8944344Medicare PIN
OR500694700Medicaid
WAG8944351Medicare PIN
WAG8944345Medicare PIN