Provider Demographics
NPI:1093166647
Name:RUDD, ROBERT MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:MATTHEW
Last Name:RUDD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1346 ISLAND PL E
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-9023
Mailing Address - Country:US
Mailing Address - Phone:731-616-8390
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE STE 447
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-448-5814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-24
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-13066207P00000X
TN390200000X
TN60077207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program