Healthcare Provider Details

I. General information

NPI: 1063414761
Provider Name (Legal Business Name): BLAIR KAICHEN DUDDY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N TENAYA WAY
LAS VEGAS NV
89128-0424
US

IV. Provider business mailing address

PO BOX 15645
LAS VEGAS NV
89114-5645
US

V. Phone/Fax

Practice location:
  • Phone: 702-243-8500
  • Fax: 702-869-5347
Mailing address:
  • Phone: 702-579-3298
  • Fax: 702-667-4689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number7316
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: