Provider Demographics
NPI:1164491940
Name:RUDIC, GORAN TODOR (MD)
Entity Type:Individual
Prefix:DR
First Name:GORAN
Middle Name:TODOR
Last Name:RUDIC
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 1:5663 S 27TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-4107
Mailing Address - Country:US
Mailing Address - Phone:414-389-3146
Mailing Address - Fax:
Practice Address - Street 1:5663 S 27TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-4107
Practice Address - Country:US
Practice Address - Phone:414-389-3146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40975207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32557800Medicaid
WI0000101273Medicare ID - Type Unspecified
WI32557800Medicaid