Provider Demographics
NPI:1942481502
Name:RUDERMAN, MARK IRA (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:IRA
Last Name:RUDERMAN
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 1:28 EAST PALISADE AVENUE
Mailing Address - Street 2:ENGLEWOOD EYE
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631
Mailing Address - Country:US
Mailing Address - Phone:201-567-2020
Mailing Address - Fax:
Practice Address - Street 1:28 EAST PALISADE AVENUE
Practice Address - Street 2:ENGLEWOOD EYE
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631
Practice Address - Country:US
Practice Address - Phone:201-567-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00409000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T84887Medicare UPIN
RU24986Medicare PIN