Provider Demographics
NPI:1831454214
Name:RUDITSER, DENNIS JASON (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:JASON
Last Name:RUDITSER
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 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:21297 OLEAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952-6704
Practice Address - Country:US
Practice Address - Phone:855-979-5700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287383314000000X
FLME123760207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility