Basic Information
Provider Information
NPI: 1003019019
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DUDNEY
FirstName: BLONIE
MiddleName: WAYNE
NamePrefix:  
NameSuffix: JR.
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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: 01/30/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207WX0107X2010014075MOY    

No ID Information.


Home