Provider Demographics
NPI:1346221173
Name:RUDIS, JOHN ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ANTHONY
Last Name:RUDIS
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 1:206 GENE SAMFORD DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3374
Mailing Address - Country:US
Mailing Address - Phone:936-637-7667
Mailing Address - Fax:936-637-2363
Practice Address - Street 1:206 GENE SAMFORD DR
Practice Address - Street 2:SUITE A
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3374
Practice Address - Country:US
Practice Address - Phone:936-637-7667
Practice Address - Fax:936-637-2363
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120513003Medicaid
TX120513004Medicaid
TXE02234Medicare UPIN
TX00B42UMedicare ID - Type Unspecified