Provider Demographics
NPI:1306931423
Name:IRON BRIDGE DIABETES & ENDO
Entity type:Organization
Organization Name:IRON BRIDGE DIABETES & ENDO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:J
Authorized Official - Last Name:DUDA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:417-879-6364
Mailing Address - Street 1:1135 E LAKEWOOD ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65810-2403
Mailing Address - Country:US
Mailing Address - Phone:417-879-6364
Mailing Address - Fax:417-879-6368
Practice Address - Street 1:1135 E LAKEWOOD ST
Practice Address - Street 2:SUITE 104
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65810-2403
Practice Address - Country:US
Practice Address - Phone:417-879-6364
Practice Address - Fax:417-879-6368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
16610OtherBLUE CROSS BLUE SHIELD
460002667OtherPTAN
MOP00266673OtherRAILROAD MEDICARE PTAN
000015170OtherMEDICARE PTAN