Provider Demographics
NPI:1184651192
Name:SUDDUTH, ROBERT HERDMAN (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:HERDMAN
Last Name:SUDDUTH
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 1:9621 RIDGETOP BLVD NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2200 NW MYHRE RD
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-7681
Practice Address - Country:US
Practice Address - Phone:360-830-1205
Practice Address - Fax:360-830-1281
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025993207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA117877OtherLABOR & INDUSTRIES
5440589OtherAETNA
WA8214132Medicaid
SU0778OtherREGENCE BLUESHIELD
110162832OtherRAILROAD MEDICARE
110162832OtherRAILROAD MEDICARE
SU0778OtherREGENCE BLUESHIELD
G61902Medicare UPIN
WAGAB02440Medicare PIN
WAGAB02439Medicare PIN
WAGAB02436Medicare PIN
WAG8851967Medicare PIN
5440589OtherAETNA
G8900013Medicare PIN