Provider Demographics
NPI:1619260387
Name:JOHN A. RUDIS, MD,PA
Entity Type:Organization
Organization Name:JOHN A. RUDIS, MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-637-6502
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:75904-3358
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:75904-3358
Practice Address - Country:US
Practice Address - Phone:936-637-7667
Practice Address - Fax:936-637-2363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH2745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX120513003Medicaid
TX00B42UOtherMEDICARE
TX120513003Medicaid