Provider Demographics
NPI:1770520538
Name:RUDDY, PATRICK J (MD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:RUDDY
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 917110
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7110
Mailing Address - Country:US
Mailing Address - Phone:800-901-2102
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:325 AVENUE 'B', NW
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-4651
Practice Address - Country:US
Practice Address - Phone:863-291-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME67160207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL26262OtherBLUE CROSS BLUE SHIELD FL
FL376422200Medicaid
FL50056275OtherRAILROAD MEDICARE
FLSSNOtherTRICARE/CHAMPUS
FL26262OtherBLUE CROSS BLUE SHIELD FL
FL50056275OtherRAILROAD MEDICARE