Provider Demographics
NPI:1841823978
Name:RUDA, AGITU M
Entity type:Individual
Prefix:
First Name:AGITU
Middle Name:M
Last Name:RUDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 E 10TH ST STE L
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-4083
Mailing Address - Country:US
Mailing Address - Phone:209-346-5551
Mailing Address - Fax:
Practice Address - Street 1:35 E 10TH ST STE L
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-4083
Practice Address - Country:US
Practice Address - Phone:209-346-5551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-18
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical