Basic Information
| Provider Information | |||||||||
| NPI: | 1003019019 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUDNEY | ||||||||
| FirstName: | BLONIE | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1224 GRAHAM RD | ||||||||
| Address2: | 3011 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148391211 | ||||||||
| FaxNumber: | 3148398429 | ||||||||
| Practice Location | |||||||||
| Address1: | 1224 GRAHAM RD | ||||||||
| Address2: | 3011 | ||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630318028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148391211 | ||||||||
| FaxNumber: | 3148398429 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2007 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207WX0107X | 2010014075 | MO | Y |
No ID Information.