Basic Information
| Provider Information | |||||||||
| NPI: | 1477728640 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FUDGE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | CURTIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FUDGE | ||||||||
| OtherFirstName: | CURT | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 100296 | ||||||||
| Address2: | UNIVERSITY OF FLORIDA COM | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326100296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522735422 | ||||||||
| FaxNumber: | 3523920547 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER ROAD | ||||||||
| Address2: | THE CONGENITAL HEART CENTER AT UF | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522735422 | ||||||||
| FaxNumber: | 3523920547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2008 | ||||||||
| LastUpdateDate: | 08/22/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | 2005-01012 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology | 208000000X | ME107837 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 149CC | 01 | FL | BCBSFL | OTHER | 003110304A | 05 | GA | MEDICAID | 002668600 | 05 | FL | MEDICAID |