Provider Demographics
NPI:1912000944
Name:RUDERMAN, JONATHAN M (MD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:M
Last Name:RUDERMAN
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 1:676 N CLAIR
Mailing Address - Street 2:#320
Mailing Address - City:CHICAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:312-475-1000
Mailing Address - Fax:312-475-1006
Practice Address - Street 1:676 N CLAIR
Practice Address - Street 2:#320
Practice Address - City:CHICAGE
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-475-1000
Practice Address - Fax:312-475-1006
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
479560Medicare ID - Type Unspecified
D 15643Medicare UPIN