Provider Demographics
NPI:1336134733
Name:RUDDOCK, TONIA L (MD)
Entity Type:Individual
Prefix:
First Name:TONIA
Middle Name:L
Last Name:RUDDOCK
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 1:107 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-6903
Mailing Address - Country:US
Mailing Address - Phone:334-828-7546
Mailing Address - Fax:334-828-7547
Practice Address - Street 1:107 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-6903
Practice Address - Country:US
Practice Address - Phone:334-828-7546
Practice Address - Fax:334-828-7547
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-13
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26056207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA140835009AMedicaid
AL051554856Medicaid