Provider Demographics
NPI:1548214927
Name:LUDDERS, DARRELL J (MD)
Entity Type:Individual
Prefix:MR
First Name:DARRELL
Middle Name:J
Last Name:LUDDERS
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 1:3340 E GOLDSTONE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1026
Mailing Address - Country:US
Mailing Address - Phone:208-367-5170
Mailing Address - Fax:208-367-5180
Practice Address - Street 1:1072 N LIBERTY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8708
Practice Address - Country:US
Practice Address - Phone:208-367-4321
Practice Address - Fax:208-367-4525
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM3180207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010159518OtherBLUE SHIELD
IDB5711OtherBLUE CROSS
ID003801000Medicaid
ID1109204Medicare ID - Type Unspecified
D43669Medicare UPIN