Healthcare Provider Details

I. General information

NPI: 1740704857
Provider Name (Legal Business Name): BENJAMIN KEITH GUDORF CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 S MAIN ST
ROCKFORD OH
45882-9228
US

IV. Provider business mailing address

PO BOX 7527
DUBLIN OH
43017-0727
US

V. Phone/Fax

Practice location:
  • Phone: 419-363-3008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.021214
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: