Healthcare Provider Details

I. General information

NPI: 1033138599
Provider Name (Legal Business Name): ERIC CLARK DUDLEY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 JW CLAY BLVD
CHARLOTTE NC
28262-5417
US

IV. Provider business mailing address

3515 SELWYN AVE
CHARLOTTE NC
28209-3501
US

V. Phone/Fax

Practice location:
  • Phone: 704-510-0816
  • Fax: 704-510-0919
Mailing address:
  • Phone: 704-521-2719
  • Fax: 704-510-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number152W00000X
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: