Healthcare Provider Details

I. General information

NPI: 1669682811
Provider Name (Legal Business Name): BENJAMIN C DUDLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MASON ST
VACAVILLE CA
95688-4646
US

IV. Provider business mailing address

10470 OLD PLACERVILLE RD SUITE 100
SACRAMENTO CA
95827-2539
US

V. Phone/Fax

Practice location:
  • Phone: 707-454-5800
  • Fax: 707-454-5809
Mailing address:
  • Phone: 800-470-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number13996
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA136154
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: