Provider Demographics
NPI:1083727770
Name:RUDD, NESHIA RENAE (OD)
Entity Type:Individual
Prefix:DR
First Name:NESHIA
Middle Name:RENAE
Last Name:RUDD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NESHIA
Other - Middle Name:RENAE
Other - Last Name:RUDD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4139 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-8720
Mailing Address - Country:US
Mailing Address - Phone:903-581-9651
Mailing Address - Fax:
Practice Address - Street 1:4139 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8720
Practice Address - Country:US
Practice Address - Phone:903-534-8349
Practice Address - Fax:903-581-8203
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5643TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00371WOtherGROUP PTAN
TX752948352OtherTAX ID
TX5634TGOtherLICENSE
TX752948352OtherTAX ID
TXU71135Medicare UPIN