Provider Demographics
NPI:1861463226
Name:RUDNICKI, DANIEL P (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:RUDNICKI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 ALLENTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2205
Mailing Address - Country:US
Mailing Address - Phone:419-228-9176
Mailing Address - Fax:419-228-5935
Practice Address - Street 1:1593 ALLENTOWN RD
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2205
Practice Address - Country:US
Practice Address - Phone:419-228-9176
Practice Address - Fax:419-228-5935
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3963-T630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT48719Medicare UPIN
OHRU0609083Medicare ID - Type Unspecified