Provider Demographics
NPI:1326146275
Name:FEDRIZZI, RUDOLPH PETER (MD)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:PETER
Last Name:FEDRIZZI
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 1:1220 TRUMANSBURG RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1314
Mailing Address - Country:US
Mailing Address - Phone:607-273-0011
Mailing Address - Fax:607-272-0240
Practice Address - Street 1:302 W SENECA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4130
Practice Address - Country:US
Practice Address - Phone:607-272-0200
Practice Address - Fax:607-272-0240
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY235229207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02644168Medicaid
NYRA7306Medicare ID - Type Unspecified
NY02644168Medicaid