Healthcare Provider Details

I. General information

NPI: 1215960026
Provider Name (Legal Business Name): LEE ANTHONY DUDLEY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5113 S HARPER AVE STE 2C
CHICAGO IL
60615
US

IV. Provider business mailing address

5113 S HARPER AVE STE 2C
CHICAGO IL
60615-4119
US

V. Phone/Fax

Practice location:
  • Phone: 773-983-1635
  • Fax:
Mailing address:
  • Phone: 773-983-1635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number336.091115
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberQ5791
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34008088
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2012-02286
License Number StateNC
# 5
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO.1490
License Number StateAL
# 6
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO034849
License Number StateDC
# 7
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2010025333
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number057958
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberH0064685
License Number StateMD
# 10
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDOS-1111
License Number StateHI
# 11
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberDO0000001892
License Number StateTN
# 12
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036.129640
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: