Provider Demographics
NPI:1477651123
Name:RUTKOVSKY, FREDERICK D (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:D
Last Name:RUTKOVSKY
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 1:19303 UNION TPKE
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1874
Mailing Address - Country:US
Mailing Address - Phone:718-468-6600
Mailing Address - Fax:
Practice Address - Street 1:19303 UNION TPKE
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1874
Practice Address - Country:US
Practice Address - Phone:718-468-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176798207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01723335Medicaid
NY01723335Medicaid
F32883Medicare UPIN
NY70K181Medicare ID - Type Unspecified