Healthcare Provider Details

I. General information

NPI: 1548525611
Provider Name (Legal Business Name): MATTHEW THOMAS DUDLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 10/05/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE STE M917
SAN FRANCISCO CA
94143-0624
US

IV. Provider business mailing address

505 PARNASSUS AVE STE M917 BOX 0624
SAN FRANCISCO CA
94143-0624
US

V. Phone/Fax

Practice location:
  • Phone: 415-514-3781
  • Fax: 415-514-0185
Mailing address:
  • Phone: 415-514-3781
  • Fax: 415-514-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146L00000X
TaxonomyParamedic
License Number3201001683
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License NumberA131338
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA131338
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: