Provider Demographics
NPI:1780631846
Name:RUDDOCK, HEATHER (MD)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:RUDDOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 ROUTE 73 N
Mailing Address - Street 2:BLDG 10, SUITE 320
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053
Mailing Address - Country:US
Mailing Address - Phone:215-774-1166
Mailing Address - Fax:215-279-8383
Practice Address - Street 1:2000 HAMILTON ST STE 301
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19130-3874
Practice Address - Country:US
Practice Address - Phone:215-774-1166
Practice Address - Fax:215-279-8383
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056728208000000X
NJ25MA08898000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01670460Medicaid
PA002705Medicare ID - Type Unspecified
PA01670460Medicaid