Basic Information
| Provider Information | |||||||||
| NPI: | 1023074853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUDZAK | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1144 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454011144 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372599900 | ||||||||
| FaxNumber: | 9372599999 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 XENIA AVE | ||||||||
| Address2: | |||||||||
| City: | YELLOW SPRINGS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453871600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9377677369 | ||||||||
| FaxNumber: | 9377677703 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 11/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35048312 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0102990 | 05 | OH | MEDICAID |