Healthcare Provider Details

I. General information

NPI: 1720067051
Provider Name (Legal Business Name): PHILIP S DUDAK DC, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2006
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11133 DUNN RD
SAINT LOUIS MO
63136-6163
US

IV. Provider business mailing address

11125 DUNN RD STE 100
SAINT LOUIS MO
63136-6132
US

V. Phone/Fax

Practice location:
  • Phone: 314-653-5228
  • Fax:
Mailing address:
  • Phone: 314-653-5228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2013003629
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209010226
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209010226
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2013003629
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number005778
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038006559
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: