Provider Demographics
NPI:1619920113
Name:RUDOY, VSEVOLOD G
Entity Type:Individual
Prefix:
First Name:VSEVOLOD
Middle Name:G
Last Name:RUDOY
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 1:1558 E 19TH ST
Mailing Address - Street 2:APT 3-H
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-7264
Mailing Address - Country:US
Mailing Address - Phone:718-613-4880
Mailing Address - Fax:718-613-4717
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-4880
Practice Address - Fax:718-613-4717
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2221472084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02175437Medicaid
NY02175437Medicaid
H46041Medicare UPIN