Provider Demographics
NPI:1528502978
Name:LAUDERDALE, BILL
Entity type:Individual
Prefix:
First Name:BILL
Middle Name:
Last Name:LAUDERDALE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WILLIAM
Other - Middle Name:H
Other - Last Name:LAUDERDALE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:MO
Mailing Address - Zip Code:65653-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:288 STATE HWY Y
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MO
Practice Address - Zip Code:65653-0010
Practice Address - Country:US
Practice Address - Phone:417-546-3357
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-05
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD.29118207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology