Basic Information
| Provider Information | |||||||||
| NPI: | 1013067578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VARNER E. DUDLEY, III, M.D., INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 S LAKE AVE | ||||||||
| Address2: | SUITE 535 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911013005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267956596 | ||||||||
| FaxNumber: | 6267958247 | ||||||||
| Practice Location | |||||||||
| Address1: | 1509 WILSON TER | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8184098000 | ||||||||
| FaxNumber: | 8185465632 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2007 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUDLEY | ||||||||
| AuthorizedOfficialFirstName: | VARNER | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6265841556 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | G55075 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00G550750 | 01 | CA | BLUE SHIELD | OTHER | 00G550750 | 05 | CA | MEDICAID |