Basic Information
| Provider Information | |||||||||
| NPI: | 1063414761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUDDY | ||||||||
| FirstName: | BLAIR | ||||||||
| MiddleName: | KAICHEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15645 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891145645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025793298 | ||||||||
| FaxNumber: | 7026674689 | ||||||||
| Practice Location | |||||||||
| Address1: | 2704 N TENAYA WAY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891280424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022438500 | ||||||||
| FaxNumber: | 7028695347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 7316 | NV | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1063414761 | 05 | NV | MEDICAID | V114364 | 01 | NV | SSMA MEDICARE | OTHER |