Provider Demographics
NPI:1083606156
Name:RUDDELL, DEANNA N (MD)
Entity Type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:N
Last Name:RUDDELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16101 CANTRELL RD STE 104
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4578
Mailing Address - Country:US
Mailing Address - Phone:501-425-0322
Mailing Address - Fax:
Practice Address - Street 1:16101 CANTRELL RD STE 104
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223-4578
Practice Address - Country:US
Practice Address - Phone:501-425-0322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN8430207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR129401001Medicaid
AR129401001Medicaid
ARG27159Medicare UPIN