Provider Demographics
NPI:1053426957
Name:RUDRICH, HORST R (DO)
Entity type:Individual
Prefix:
First Name:HORST
Middle Name:R
Last Name:RUDRICH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 EDGEHILL LN
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6523
Mailing Address - Country:US
Mailing Address - Phone:909-798-3061
Mailing Address - Fax:909-793-9173
Practice Address - Street 1:255 TERRACINA BLVD
Practice Address - Street 2:STE. 105
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-793-0323
Practice Address - Fax:909-793-9173
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5970207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX59700OtherMEDI-CAL
CA00AX59700Medicaid
CA00AX59700OtherMEDI-CAL
CA080190100Medicare ID - Type UnspecifiedMEDICARE RAIL ROAD
CA020A59701Medicare ID - Type UnspecifiedMEDICARE