Healthcare Provider Details

I. General information

NPI: 1316111412
Provider Name (Legal Business Name): STEPHEN CHRISTOPHER DUDLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2008
Last Update Date: 05/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PROFESSIONAL PL 303
CARROLLTON GA
30117-3874
US

IV. Provider business mailing address

119 AMBULANCE DR 202
CARROLLTON GA
30117-3857
US

V. Phone/Fax

Practice location:
  • Phone: 770-812-5793
  • Fax: 880-812-5784
Mailing address:
  • Phone: 770-838-8710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number061845
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number061845
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: