1144223678 NPI number — MR. MARK DUDLEY APRN

Table of content: MR. MARK DUDLEY APRN (NPI 1144223678)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144223678 NPI number — MR. MARK DUDLEY APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUDLEY
Provider First Name:
MARK
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DUDLEY
Provider Other First Name:
MARK
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1144223678
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:
2386 SNOW MOUNTAIN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84093-1753
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-733-4376
Provider Business Mailing Address Fax Number:
801-466-3195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1399 S 700 E STE 11B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84105-2149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-918-9890
Provider Business Practice Location Address Fax Number:
801-466-3195
Provider Enumeration Date:
05/30/2005

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: 364SP0809X , with the licence number:  1361364405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 94293834884047A017 . This is a "CHAMPUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107002906101 . This is a "INTERMOUNTAIN HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 262137 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: P33212 . This is a "MEDICARE ADVANTAGE PLUS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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