Provider Demographics
NPI:1871756353
Name:RUDERSDORF, JOHN CONRAD (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:CONRAD
Last Name:RUDERSDORF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 INVERNESS DR W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-5095
Mailing Address - Country:US
Mailing Address - Phone:303-779-9676
Mailing Address - Fax:
Practice Address - Street 1:10350 DRANSFELDT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-9673
Practice Address - Country:US
Practice Address - Phone:303-805-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-06
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20080140012084P0800X
CODR.00554612084P0804X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry