Provider Demographics
NPI:1336121862
Name:TAAREA, RUDY HARTONO (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDY
Middle Name:HARTONO
Last Name:TAAREA
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 1:511 BRANTLEY ST
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-1702
Mailing Address - Country:US
Mailing Address - Phone:334-493-3240
Mailing Address - Fax:
Practice Address - Street 1:511 BRANTLEY ST
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1702
Practice Address - Country:US
Practice Address - Phone:334-493-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAL194832083A0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083A0100XAllopathic & Osteopathic PhysiciansPreventive MedicineAerospace Medicine