MEDICARE: DANIEL A DUDLEY O.D.

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	152W00000X	Optometrist	4901002802	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	900A165160	OTHER	MI	BLUE CROSS BLUE SHIELD OF MICHIGAN

General Provider Information

NPI Number	:	1962539163
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL A DUDLEY O.D.

Provider Business Mailing Address
First Line	:	2904 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:	269-983-2020
Fax Number	:	269-983-3651

Provider Business Practice Location Address
First Line	:	2904 DIVISION ST
Second Line	:
City	:	SAINT JOSEPH
State	:	MI
Zip	:	49085-2437
Country	:	US
Telephone Number	:	269-983-2020
Fax Number	:	269-983-3651

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	06/26/2008

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