Provider Demographics
NPI:1255367280
Name:RUNDBACK, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:RUNDBACK
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:BRIARCLIFF MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10510-0405
Mailing Address - Country:US
Mailing Address - Phone:201-227-6210
Mailing Address - Fax:201-643-3077
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:201-227-6210
Practice Address - Fax:201-643-3077
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0797912085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6299806Medicaid
NJ97447Medicare ID - Type Unspecified
NJF53964Medicare UPIN