Provider Demographics
NPI:1033100615
Name:RUDBERG, THEODORE L (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:L
Last Name:RUDBERG
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 1:5430 E SAPPHIRE LN
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-2533
Mailing Address - Country:US
Mailing Address - Phone:602-410-3293
Mailing Address - Fax:
Practice Address - Street 1:5430 E SAPPHIRE LN
Practice Address - Street 2:
Practice Address - City:PARADISE VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85253-2533
Practice Address - Country:US
Practice Address - Phone:602-410-3293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11018207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ0000BGJNCMedicaid
029229OtherAM. BOARD OF FAMILY PRACT
D00218Medicare UPIN