Healthcare Provider Details

I. General information

NPI: 1053011924
Provider Name (Legal Business Name): JOHN DUDLEY FUSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2023
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 HAZEN ST
PAW PAW MI
49079-2008
US

IV. Provider business mailing address

801 HAZEN ST
PAW PAW MI
49079-2008
US

V. Phone/Fax

Practice location:
  • Phone: 269-657-5574
  • Fax:
Mailing address:
  • Phone: 269-657-5574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: