Provider Demographics
NPI:1407919160
Name:RUDNICKI, RICHARD N (DO)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:N
Last Name:RUDNICKI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3330 N GALLOWAY AVE STE 304
Mailing Address - Street 2:PMB 91
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4767
Mailing Address - Country:US
Mailing Address - Phone:214-796-9383
Mailing Address - Fax:
Practice Address - Street 1:3330 N GALLOWAY AVE STE 304
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4767
Practice Address - Country:US
Practice Address - Phone:972-289-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-17
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ2769207ND0101X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0847576-01Medicaid
TX00R37RMedicare ID - Type Unspecified
TX0847576-01Medicaid
TXE61621Medicare UPIN