Provider Demographics
NPI:1598442766
Name:FONDEUR ACOSTA, JUAN RUDDY (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:RUDDY
Last Name:FONDEUR ACOSTA
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 1:529 4TH ST
Mailing Address - Street 2:
Mailing Address - City:EAST NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11731
Mailing Address - Country:US
Mailing Address - Phone:929-633-0990
Mailing Address - Fax:
Practice Address - Street 1:1650 GRAND CONCOURSE BRONX-LEBANON HOSPITAL CENTER,
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457
Practice Address - Country:US
Practice Address - Phone:701-901-8203
Practice Address - Fax:718-901-8704
Is Sole Proprietor?:No
Enumeration Date:2023-06-29
Last Update Date:2024-06-18
Deactivation Date:2024-02-02
Deactivation Code:
Reactivation Date:2024-06-18
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program