Basic Information
Provider Information | |||||||||
NPI: | 1457321580 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BUDDE | ||||||||
FirstName: | DOUGLAS | ||||||||
MiddleName: | R | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 915 S RAINBOW BLVD | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891456230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7252208667 | ||||||||
FaxNumber: | 8337490353 | ||||||||
Practice Location | |||||||||
Address1: | 915 S RAINBOW BLVD | ||||||||
Address2: |   | ||||||||
City: | LAS VEGAS | ||||||||
State: | NV | ||||||||
PostalCode: | 891456230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7252208667 | ||||||||
FaxNumber: | 8337490353 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 12/14/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10543 | NV | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | CI7026 | 01 | NV | GROUP RAILROAD MEDICARE | OTHER | P00054854 | 01 | NV | RAILROAD MEDICARE | OTHER | 1457321580 | 05 | NV |   | MEDICAID | GD340Z | 01 | NV | MEDICARE PTAN | OTHER |