Provider Demographics
NPI:1730197302
Name:DUDICH, TIM MYRON
Entity type:Individual
Prefix:
First Name:TIM
Middle Name:MYRON
Last Name:DUDICH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NE LOOP 410 STE 900
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-5831
Mailing Address - Country:US
Mailing Address - Phone:210-375-7780
Mailing Address - Fax:
Practice Address - Street 1:45 NE LOOP 410 STE 900
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-5831
Practice Address - Country:US
Practice Address - Phone:210-375-7780
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
50574231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist