Provider Demographics
NPI:1407006364
Name:RUDLOFF, NICHOLAS ADAM (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ADAM
Last Name:RUDLOFF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 NW PLATTE RD STE 120
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:MO
Mailing Address - Zip Code:64150-7500
Mailing Address - Country:US
Mailing Address - Phone:816-472-0400
Mailing Address - Fax:
Practice Address - Street 1:1805 NW PLATTE RD STE 120
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:MO
Practice Address - Zip Code:64150-7500
Practice Address - Country:US
Practice Address - Phone:816-472-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-26
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014025262207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty