Provider Demographics
NPI:1033254974
Name:RUDNICK, MICHAEL DENNIS (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:DENNIS
Last Name:RUDNICK
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28101 E QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:WATKINS
Mailing Address - State:CO
Mailing Address - Zip Code:80137-9502
Mailing Address - Country:US
Mailing Address - Phone:303-214-1131
Mailing Address - Fax:303-766-2042
Practice Address - Street 1:28101 E QUINCY AVE
Practice Address - Street 2:
Practice Address - City:WATKINS
Practice Address - State:CO
Practice Address - Zip Code:80137-9502
Practice Address - Country:US
Practice Address - Phone:303-214-1131
Practice Address - Fax:303-766-2042
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO301302080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01301308Medicaid