Provider Demographics
NPI:1447362058
Name:FUDALA, RONALD D (DC,DACAN)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:D
Last Name:FUDALA
Suffix:
Gender:M
Credentials:DC,DACAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1301 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 402A
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3108
Mailing Address - Country:US
Mailing Address - Phone:904-471-4744
Mailing Address - Fax:904-471-4745
Practice Address - Street 1:1301 PLANTATION ISLAND DR S
Practice Address - Street 2:SUITE 402 A
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-3108
Practice Address - Country:US
Practice Address - Phone:904-471-4744
Practice Address - Fax:901-471-4745
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1317111NN0400X
FLCH10979111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000206217OtherANTHEM
44-00470OtherUNITED HEALTHCARE
2501109OtherAETNA
T48640Medicare UPIN