MEDICARE: DUDDLESTON MANAGEMENT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1154876290
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DUDDLESTON MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	PO BOX 9178
Second Line	:
City	:	RUSSELLVILLE
State	:	AR
Zip	:	72811-9178
Country	:	US
Telephone Number	:	479-498-6700
Fax Number	:	479-968-4331

Provider Business Practice Location Address
First Line	:	1116 FOREST AVE
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39206-3216
Country	:	US
Telephone Number	:	601-291-1993
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DAVID DUDDLESTON
Credential	:	MD
Telephone Number	:	601-291-1993

Provider Enumeration Date	:	08/18/2016
Last Update Date	:	08/18/2016

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