Healthcare Provider Details

I. General information

NPI: 1003019019
Provider Name (Legal Business Name): BLONIE WAYNE DUDNEY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 GRAHAM RD 3011
FLORISSANT MO
63031-8028
US

IV. Provider business mailing address

1224 GRAHAM RD 3011
FLORISSANT MO
63031-8028
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-1211
  • Fax: 314-839-8429
Mailing address:
  • Phone: 314-839-1211
  • Fax: 314-839-8429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number2010014075
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: