Provider Demographics
NPI:1346200706
Name:RUDY, DAVID R (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:RUDY
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 1:1633 TIMBERLAKE DR
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015-8897
Mailing Address - Country:US
Mailing Address - Phone:740-549-7665
Mailing Address - Fax:740-549-0130
Practice Address - Street 1:1633 TIMBERLAKE DR
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-8897
Practice Address - Country:US
Practice Address - Phone:740-549-7665
Practice Address - Fax:740-549-0130
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036082096207Q00000X
OH35-0243412083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036082096Medicaid
IL036082096Medicaid
ILL15410Medicare ID - Type Unspecified