Provider Demographics
NPI:1548399843
Name:DUDEWICZ, DOUGLAS M (MD)
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:M
Last Name:DUDEWICZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:RM 111, BLDG 6588
Mailing Address - Street 2:6588 NORTH DELAWARE AVE
Mailing Address - City:FORT KNOX
Mailing Address - State:KY
Mailing Address - Zip Code:40121-5123
Mailing Address - Country:US
Mailing Address - Phone:502-626-2014
Mailing Address - Fax:
Practice Address - Street 1:IRELAND ARMY HEALTH CLINIC
Practice Address - Street 2:BLDG 871, 200 BRULE ST
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5123
Practice Address - Country:US
Practice Address - Phone:502-626-2014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-04
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD000Medicare UPIN