Provider Demographics
NPI:1467479915
Name:RUDNICK, DAVID A (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:RUDNICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-6173
Mailing Address - Fax:844-231-8912
Practice Address - Street 1:1 CHILDRENS PL
Practice Address - Street 2:DIV PED GASTRO, HEPATOLOGY AND NUTRITION
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1002
Practice Address - Country:US
Practice Address - Phone:314-454-6173
Practice Address - Fax:844-231-8912
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106362208000000X, 2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205020209Medicaid
ILENROLLEDMedicaid
TN1517239Medicaid
IL$$$$$$$$$Medicaid
MO232010381Medicaid