Provider Demographics
NPI:1154676542
Name:RUDDY, STEPHANIE MAUS (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MAUS
Last Name:RUDDY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:MARIE
Other - Last Name:MAUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:4160 LITTLE YORK RD STE 20
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5803
Mailing Address - Country:US
Mailing Address - Phone:937-454-9527
Mailing Address - Fax:937-454-9532
Practice Address - Street 1:4160 LITTLE YORK RD STE 20
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-5803
Practice Address - Country:US
Practice Address - Phone:937-454-9527
Practice Address - Fax:937-454-9532
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012093207RC0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0315554Medicaid