1114958592 NPI number — VARNER EDWARD DUDLEY III M.D.

Table of content: VARNER EDWARD DUDLEY III M.D. (NPI 1114958592)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114958592 NPI number — VARNER EDWARD DUDLEY III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUDLEY
Provider First Name:
VARNER
Provider Middle Name:
EDWARD
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114958592
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
225 S LAKE AVE
Provider Second Line Business Mailing Address:
535
Provider Business Mailing Address City Name:
PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91101-3005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-795-6596
Provider Business Mailing Address Fax Number:
626-795-8247

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1509 WILSON TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLENDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91206-4007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-409-8000
Provider Business Practice Location Address Fax Number:
818-546-5632
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  G55075 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00G550750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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