MEDICARE: DR. HEATHER L DUDLEY DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	036113156	IL
2	207V00000X	Obstetrics & Gynecology Physician	OS14575	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1356320592	OTHER	FL	NPI

General Provider Information

NPI Number	:	1356320592
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HEATHER L DUDLEY DO

Provider Business Mailing Address
First Line	:	1658 ST VINCENTS WAY STE 130
Second Line	:
City	:	MIDDLEBURG
State	:	FL
Zip	:	32068-8459
Country	:	US
Telephone Number	:	904-264-1628
Fax Number	:	904-264-8386

Provider Business Practice Location Address
First Line	:	1658 ST VINCENTS WAY STE 130
Second Line	:
City	:	MIDDLEBURG
State	:	FL
Zip	:	32068-8459
Country	:	US
Telephone Number	:	904-264-1628
Fax Number	:	904-264-8386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2006
Last Update Date	:	06/16/2018

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Directions to “ DR. HEATHER L DUDLEY DO” Practice Location

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