Basic Information
| Provider Information | |||||||||
| NPI: | 1598802670 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUDD | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | OTIS | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094743568 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 122 W 7TH AVE STE 232 | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992042354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094742041 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 79755 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RA0001X | MD152479 | OR | N | 207RA0001X | 79755 | MT | N | 207RC0000X | MD152479 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | MD60896935 | WA | Y |
ID Information
| ID | Type | State | Issuer | Description | 500629287 | 05 | OR | MEDICAID |