1043291024 NPI number — JOHN RUDOFF M.D.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	RUDOFF
Provider First Name	:	JOHN
Provider Middle Name	:
Provider Name Prefix Text	:
Provider Name Suffix Text	:
Provider Credential Text	:	M.D.
Provider Gender Code	:	M

Provider Other Organization Name	:
Provider Other Organization Name Type Code	:
Provider Other Last Name	:
Provider Other First Name	:
Provider Other Middle Name	:
Provider Other Name Prefix Text	:
Provider Other Name Suffix Text	:
Provider Other Credential Text	:
Provider Other Last Name Type Code	:

NPI Number	:	1043291024
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
NPI Deactivation Date	:
NPI Reactivation Date	:

Provider First Line Business Mailing Address	:	6475 SW BORLAND RD
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	TUALATIN
Provider Business Mailing Address State Name	:	OR
Provider Business Mailing Address Postal Code	:	970629708
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5032388333
Provider Business Mailing Address Fax Number	:	5038859033

Provider First Line Business Practice Location Address	:	6475 SW BORLAND RD
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	TUALATIN
Provider Business Practice Location Address State Name	:	OR
Provider Business Practice Location Address Postal Code	:	970629708
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	5032388333
Provider Business Practice Location Address Fax Number	:	5038859033
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
Authorized Official Middle Name	:
Authorized Official Title or Position	:
Authorized Official Telephone Number	:

• Taxonomy code: 174400000X , with the licence number:  MD16036 , registered in the state of OR .

• Identifier: C67726 , issued by the state of ( OR ) . This identifiers is of the category "".
• Identifier: R0000BKXBY , issued by the state of ( OR ) . This identifiers is of the category "".
• Identifier: 099861 , issued by the state of ( OR ) . This identifiers is of the category "".