Healthcare Provider Details

I. General information

NPI: 1336123454
Provider Name (Legal Business Name): GARY FUDEM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 12/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE DEPARTMENT OF PLASTIC & RECONSTRUCTIVE SURGERY
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-5735
  • Fax:
Mailing address:
  • Phone: 206-543-6420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD60484351
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: