Provider Demographics
NPI:1679936348
Name:RUDEK, BRYCE (ATC)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:
Last Name:RUDEK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1390 N HERITAGE LN
Mailing Address - Street 2:APT 25
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-2136
Mailing Address - Country:US
Mailing Address - Phone:580-512-5506
Mailing Address - Fax:
Practice Address - Street 1:591 PENDLETON ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-2271
Practice Address - Country:US
Practice Address - Phone:918-458-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT4225207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine