Provider Demographics
NPI:1871808402
Name:DUDLEY, BRUCE W (DPT)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:W
Last Name:DUDLEY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17210 VAN WAGONER RD
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-9702
Mailing Address - Country:US
Mailing Address - Phone:616-296-2262
Mailing Address - Fax:616-935-3535
Practice Address - Street 1:17210 VAN WAGONER RD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-9702
Practice Address - Country:US
Practice Address - Phone:616-296-2262
Practice Address - Fax:616-935-3535
Is Sole Proprietor?:No
Enumeration Date:2010-08-06
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60182844225800000X
MI5501016218225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP14760014Medicare PIN
MIP14760014Medicare PIN
WAG8905388Medicare PIN