Basic Information
| Provider Information | |||||||||
| NPI: | 1538604947 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDD | ||||||||
| FirstName: | DALTON | ||||||||
| MiddleName: | BRYANT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | J.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 309 S 5TH ST | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730302916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803690723 | ||||||||
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| Practice Location | |||||||||
| Address1: | 202 S WASHITA AVE | ||||||||
| Address2: | |||||||||
| City: | WYNNEWOOD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730987820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056654385 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/21/2016 | ||||||||
| LastUpdateDate: | 12/21/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |
No ID Information.