Provider Demographics
NPI:1639124779
Name:RUDBERG, AVIDAH H (MD)
Entity Type:Individual
Prefix:
First Name:AVIDAH
Middle Name:H
Last Name:RUDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:156 BEACH 143RD ST
Mailing Address - Street 2:
Mailing Address - City:NEPONSIT
Mailing Address - State:NY
Mailing Address - Zip Code:11694-1105
Mailing Address - Country:US
Mailing Address - Phone:516-569-0696
Mailing Address - Fax:516-569-3677
Practice Address - Street 1:231 OCEAN VIEW AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-6824
Practice Address - Country:US
Practice Address - Phone:718-934-7800
Practice Address - Fax:516-569-3677
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY190637-1208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01583691Medicaid
G08521Medicare UPIN
NY23623RA971Medicare PIN