Provider Demographics
NPI:1265484299
Name:JOHNSRUDE, THEODORE EUGENE (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:EUGENE
Last Name:JOHNSRUDE
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 1:2512 WHEATON WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-3399
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9398 RIDGETOP BLVD NW
Practice Address - Street 2:
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8505
Practice Address - Country:US
Practice Address - Phone:360-782-3200
Practice Address - Fax:360-782-3245
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00019724208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA75433OtherLABOR & INDUSTRIES
WA8316200Medicaid
5358025OtherAETNA
JO4187OtherREGENCE BLUE SHIELD
JO4187OtherREGENCE BLUE SHIELD
WA75433OtherLABOR & INDUSTRIES
5358025OtherAETNA
WAGAB05619Medicare PIN