Provider Demographics
NPI:1114084399
Name:RUDERMAN, ADA (MD)
Entity Type:Individual
Prefix:
First Name:ADA
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 1:1208 AVENUE Z
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4302
Mailing Address - Country:US
Mailing Address - Phone:718-368-2699
Mailing Address - Fax:718-368-2544
Practice Address - Street 1:1208 AVENUE Z
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4302
Practice Address - Country:US
Practice Address - Phone:718-368-2699
Practice Address - Fax:718-368-2544
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2057822080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01750150Medicaid
NY01750150Medicaid
NY541981Medicare ID - Type Unspecified