Provider Demographics
NPI:1093701377
Name:RUDERMAN, TATYANA (MD)
Entity Type:Individual
Prefix:DR
First Name:TATYANA
Middle Name:
Last Name:RUDERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-4321
Mailing Address - Country:US
Mailing Address - Phone:718-436-0771
Mailing Address - Fax:718-436-8118
Practice Address - Street 1:5410 15TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4321
Practice Address - Country:US
Practice Address - Phone:718-436-0771
Practice Address - Fax:718-436-8118
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2019-02-26
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
NY218176208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02110589Medicaid