Provider Demographics
NPI:1851492086
Name:RUDIN, BRUCE A (DPM)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:RUDIN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11596-2347
Mailing Address - Country:US
Mailing Address - Phone:516-746-7245
Mailing Address - Fax:
Practice Address - Street 1:101 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON PARK
Practice Address - State:NY
Practice Address - Zip Code:11596-2347
Practice Address - Country:US
Practice Address - Phone:516-746-7245
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003432213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00763039Medicaid
T51121Medicare UPIN
NYP37181Medicare ID - Type Unspecified