Provider Demographics
NPI:1811198344
Name:BUDIHARDJO, PHILIP (DO)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:BUDIHARDJO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 MIDLAND RD STE 120
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-2339
Mailing Address - Country:US
Mailing Address - Phone:608-743-9313
Mailing Address - Fax:608-743-9318
Practice Address - Street 1:1969 W HART RD
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511
Practice Address - Country:US
Practice Address - Phone:608-362-7888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA39772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP00756372Medicare PIN
IAI09230198Medicare PIN