Provider Demographics
NPI:1831275759
Name:RUDICK, MARTIN BRUCE (OD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:BRUCE
Last Name:RUDICK
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 1:28923 CHRISTOPHER LN.
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034
Mailing Address - Country:US
Mailing Address - Phone:734-358-3669
Mailing Address - Fax:
Practice Address - Street 1:28923 CHRISTOPHER LN.
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034
Practice Address - Country:US
Practice Address - Phone:734-358-3669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2016-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003029152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5330000967OtherBOARD OF PHARMACY CONTROLLED SUBSTANCE LICENSE
MI1831275759Medicaid
MI6843015OtherPTAN
MI5330000967OtherBOARD OF PHARMACY CONTROLLED SUBSTANCE LICENSE
MI1831275759Medicaid
1831275759Medicare NSC