Healthcare Provider Details

I. General information

NPI: 1942544762
Provider Name (Legal Business Name): DUDLLEY ROLAND HURST HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6825 STATE ROAD 54
NEW PORT RICHEY FL
34653-6019
US

IV. Provider business mailing address

6825 STATE ROAD 54
NEW PORT RICHEY FL
34653
US

V. Phone/Fax

Practice location:
  • Phone: 727-842-8838
  • Fax: 727-842-6954
Mailing address:
  • Phone: 727-842-8838
  • Fax: 727-842-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS2664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: