Provider Demographics
NPI:1467483404
Name:RUDIN, CHARLES M (MD, PHD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:M
Last Name:RUDIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10017-6706
Mailing Address - Country:US
Mailing Address - Phone:646-888-4336
Mailing Address - Fax:646-888-4676
Practice Address - Street 1:1275 YORK AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-6007
Practice Address - Country:US
Practice Address - Phone:646-888-4336
Practice Address - Fax:646-888-4676
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD61040207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD403573900Medicaid
MDKR52J638Medicare PIN
MD403573900Medicaid