Provider Demographics
NPI:1124083704
Name:RUDICK, JONATHAN BRETT (MD)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:BRETT
Last Name:RUDICK
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 1:7331 HANOVER PKWY
Mailing Address - Street 2:STE B
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770
Mailing Address - Country:US
Mailing Address - Phone:301-345-0605
Mailing Address - Fax:301-345-0606
Practice Address - Street 1:7331 HANOVER PKWY
Practice Address - Street 2:STE B
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3621
Practice Address - Country:US
Practice Address - Phone:301-345-0605
Practice Address - Fax:301-345-0606
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053785207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
61090905OtherBSMD
F4550002OtherBSDC
LX76CEOtherBSMD
MD00A612C73OtherMEDICARE
MD970900200Medicaid
DCG00573Medicare ID - Type Unspecified
H32545Medicare UPIN