Healthcare Provider Details

I. General information

NPI: 1346477882
Provider Name (Legal Business Name): CLARA CHANLEY H DUDLEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2009
Last Update Date: 01/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 PARK ST
JACKSONVILLE FL
32204-3811
US

IV. Provider business mailing address

2121 PARK ST
JACKSONVILLE FL
32204-3811
US

V. Phone/Fax

Practice location:
  • Phone: 904-387-6200
  • Fax:
Mailing address:
  • Phone: 904-387-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number251156
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: