Basic Information
| Provider Information | |||||||||
| NPI: | 1265484299 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSRUDE | ||||||||
| FirstName: | THEODORE | ||||||||
| MiddleName: | EUGENE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2512 WHEATON WAY | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983103399 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9398 RIDGETOP BLVD NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823200 | ||||||||
| FaxNumber: | 3607823245 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 10/30/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD00019724 | WA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 75433 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8316200 | 05 | WA | MEDICAID | 5358025 | 01 | AETNA | OTHER | AJ6983375 | 01 | DEA | OTHER | JO4187 | 01 | REGENCE BLUE SHIELD | OTHER |