Healthcare Provider Details

I. General information

NPI: 1679669931
Provider Name (Legal Business Name): ANN DAVINA TUDDENHAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SHUMAN AVE
AUGUSTA ME
04330-6020
US

IV. Provider business mailing address

12 SHUMAN AVE
AUGUSTA ME
04330-6020
US

V. Phone/Fax

Practice location:
  • Phone: 855-239-3556
  • Fax: 207-502-1138
Mailing address:
  • Phone: 855-239-3556
  • Fax: 207-502-1138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number014495
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: