Provider Demographics
NPI:1740286210
Name:RUDLOFF, MARTIN D (MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:D
Last Name:RUDLOFF
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 1:851 E 5TH ST
Mailing Address - Street 2:STE 124
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3130
Mailing Address - Country:US
Mailing Address - Phone:636-390-8880
Mailing Address - Fax:636-390-8886
Practice Address - Street 1:851 E 5TH ST
Practice Address - Street 2:STE 124
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-3130
Practice Address - Country:US
Practice Address - Phone:636-390-8880
Practice Address - Fax:636-390-8886
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOMDR7D40208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOG35177Medicare UPIN