Provider Demographics
NPI:1891762902
Name:RUDNICKI, ROBERT DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DAVID
Last Name:RUDNICKI
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 1:701 COTTAGE GROVE RD
Mailing Address - Street 2:STE C230
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002
Mailing Address - Country:US
Mailing Address - Phone:860-242-5777
Mailing Address - Fax:860-286-2972
Practice Address - Street 1:701 COTTAGE GROVE RD
Practice Address - Street 2:STE C230
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002
Practice Address - Country:US
Practice Address - Phone:860-242-5777
Practice Address - Fax:860-286-2972
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT15878207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT115878Medicaid
CT490000046Medicare ID - Type Unspecified
CT115878Medicaid