Provider Demographics
NPI:1033258363
Name:RUTKOWSKY, DIANE (MA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:RUTKOWSKY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SHERWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHOREHAM
Mailing Address - State:NY
Mailing Address - Zip Code:11786
Mailing Address - Country:US
Mailing Address - Phone:631-403-4885
Mailing Address - Fax:631-425-4670
Practice Address - Street 1:28 N. COUNTRY RD.
Practice Address - Street 2:SUITE 201
Practice Address - City:MT. SINAI
Practice Address - State:NY
Practice Address - Zip Code:11766
Practice Address - Country:US
Practice Address - Phone:631-403-4885
Practice Address - Fax:631-425-4670
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001371-1231H00000X
NY14000007431237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM7571OtherEMPIRE
NYM7571OtherEMPIRE
NYMA006M8322Medicare PIN