Healthcare Provider Details

I. General information

NPI: 1407006364
Provider Name (Legal Business Name): NICHOLAS ADAM RUDLOFF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2008
Last Update Date: 02/18/2021
Certification Date: 02/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 NW PLATTE RD STE 120
RIVERSIDE MO
64150-7500
US

IV. Provider business mailing address

1805 NW PLATTE RD STE 120
RIVERSIDE MO
64150-7500
US

V. Phone/Fax

Practice location:
  • Phone: 816-472-0400
  • Fax:
Mailing address:
  • Phone: 816-472-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2014025262
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: