Provider Demographics
NPI:1487673331
Name:RUDDY, JOHN MATTHEW (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MATTHEW
Last Name:RUDDY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 LAKE AVE S
Mailing Address - Street 2:
Mailing Address - City:NESCONSET
Mailing Address - State:NY
Mailing Address - Zip Code:11767-1845
Mailing Address - Country:US
Mailing Address - Phone:631-786-9147
Mailing Address - Fax:
Practice Address - Street 1:51 FROST ST
Practice Address - Street 2:
Practice Address - City:WESTBURY
Practice Address - State:NY
Practice Address - Zip Code:11590-5007
Practice Address - Country:US
Practice Address - Phone:516-730-5043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY70 011261111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor