Provider Demographics
NPI:1396763793
Name:RUDEEN, RANDALL L (MD)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:L
Last Name:RUDEEN
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 1:4424 E FLAMINGO AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9300
Practice Address - Country:US
Practice Address - Phone:208-288-4888
Practice Address - Fax:208-288-4890
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5040174400000X
IDM-5040207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002648200Medicaid
ID1120819Medicare ID - Type Unspecified
IDC47924Medicare UPIN