Provider Demographics
NPI:1699871731
Name:RUDZINSKI, ROGER R (MA,PT)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:R
Last Name:RUDZINSKI
Suffix:
Gender:M
Credentials:MA,PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 AVENUE A
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-1504
Mailing Address - Country:US
Mailing Address - Phone:201-858-0786
Mailing Address - Fax:201-858-0786
Practice Address - Street 1:415 AVENUE A
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-1504
Practice Address - Country:US
Practice Address - Phone:201-858-0786
Practice Address - Fax:201-858-0786
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-16
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00517500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2523912OtherUNITED HEALTHCARE
NJ2521524OtherCIGNA HEALTHCARE
NJ080139Medicare UPIN
NJ2523912OtherUNITED HEALTHCARE