Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 111NN0400X | Neurology | 1317 | OH |
Y | 111NN0400X | Neurology | CH10979 | FL |
NPI | 1447362058 |
---|---|
Provider Name | Dr. Ronald D Fudala |
First Address | Saint Augustine, FL 32080-3108 |
Second Address | Saint Augustine, FL 32080-3108 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/08/2006 |
Last Update Date | 05/02/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000000206217 | ANTHEM (01) | |
2501109 | AETNA (01) | |
44-00470 | UNITED HEALTHCARE (01) | |
T48640 | (02) |