Provider Demographics
NPI:1598704488
Name:ROUDER DPM, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:ROUDER DPM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 RICHMOND AVE
Mailing Address - Street 2:104
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-3940
Mailing Address - Country:US
Mailing Address - Phone:178-556-5550
Mailing Address - Fax:718-273-3232
Practice Address - Street 1:1500 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3912
Practice Address - Country:US
Practice Address - Phone:178-556-5550
Practice Address - Fax:718-273-3232
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005371213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7426305Medicaid
NY05402Medicare PIN
NJ7426305Medicaid
NYU66241Medicare UPIN
NJ002402Medicare PIN
NY5548720001Medicare NSC