Provider Demographics
NPI:1043219454
Name:PUDERBAUGH, STEVEN L (DO)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:L
Last Name:PUDERBAUGH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 N. 36TH ST.
Mailing Address - Street 2:
Mailing Address - City:ST. JOSEPH
Mailing Address - State:MO
Mailing Address - Zip Code:64506-4613
Mailing Address - Country:US
Mailing Address - Phone:800-952-8387
Mailing Address - Fax:913-758-8387
Practice Address - Street 1:1314 N 36TH ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MO
Practice Address - Zip Code:64506-2357
Practice Address - Country:US
Practice Address - Phone:800-952-8387
Practice Address - Fax:913-758-8387
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS523056207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSE59088Medicare UPIN