Provider Demographics
NPI:1639512833
Name:PUDER, ROBERT D (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:PUDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 WESTERN BLVD STE L2
Mailing Address - Street 2:#292
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6755
Mailing Address - Country:US
Mailing Address - Phone:910-378-0672
Mailing Address - Fax:
Practice Address - Street 1:1250 WESTERN BLVD STE L2
Practice Address - Street 2:#292
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6755
Practice Address - Country:US
Practice Address - Phone:910-378-0672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE46132084P0800X
VA01010428112084P0800X
NY1685642084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry