Provider Demographics
NPI:1952396061
Name:LUDER, JACOB K (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:K
Last Name:LUDER
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 1:705 HURON DR
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MO
Mailing Address - Zip Code:65753-1117
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:705 HURON DR
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MO
Practice Address - Zip Code:65753-1117
Practice Address - Country:US
Practice Address - Phone:417-239-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000151553207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR158591001Medicaid
MO204957120Medicaid
MO430998OtherHEALTHLINK
OK200077430AMedicaid
MO194111OtherBCBS
MO11171OtherCOX HEALTH
MO204957104Medicaid
MOP00194821OtherRAILROAD
MO20174319965616B003OtherTRICARE
MO010014481Medicare PIN