Provider Demographics
NPI:1417049024
Name:RUDER, ROBERT OWEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:OWEN
Last Name:RUDER
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 1:8816 BURTON WAY FIRST FLOOR
Mailing Address - Street 2:
Mailing Address - City:BEVERLY HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90211-1715
Mailing Address - Country:US
Mailing Address - Phone:310-285-9612
Mailing Address - Fax:310-285-9615
Practice Address - Street 1:8816 BURTON WAY FIRST FLOOR
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-1715
Practice Address - Country:US
Practice Address - Phone:310-285-9612
Practice Address - Fax:310-285-9615
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21536207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G215360Medicaid
A90714Medicare UPIN
CA00G215360Medicaid