Provider Demographics
NPI:1225082001
Name:KNAACK, RUDOLPH H (MD)
Entity Type:Individual
Prefix:
First Name:RUDOLPH
Middle Name:H
Last Name:KNAACK
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 1:275 SE CABOT DRIVE
Mailing Address - Street 2:SUITE B101
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277
Mailing Address - Country:US
Mailing Address - Phone:360-675-6648
Mailing Address - Fax:360-679-2487
Practice Address - Street 1:275 SE CABOT DRIVE
Practice Address - Street 2:SUITE B101
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277
Practice Address - Country:US
Practice Address - Phone:360-675-6648
Practice Address - Fax:360-679-2487
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013905207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1719301Medicaid
A09049Medicare UPIN
WA1719301Medicaid