Basic Information
| Provider Information | |||||||||
| NPI: | 1356320592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUDLEY | ||||||||
| FirstName: | HEATHER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COKER | ||||||||
| OtherFirstName: | HEATHER | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1658 ST VINCENTS WAY STE 130 | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320688459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042641628 | ||||||||
| FaxNumber: | 9042648386 | ||||||||
| Practice Location | |||||||||
| Address1: | 1658 ST VINCENTS WAY STE 130 | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320688459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042641628 | ||||||||
| FaxNumber: | 9042648386 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/16/2006 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 036113156 | IL | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | OS14575 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 1356320592 | 01 | FL | NPI | OTHER |