Provider Demographics
NPI:1700977311
Name:RUDERMAN, STEVEN R (MD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:R
Last Name:RUDERMAN
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 1:9850 GENESEE AVE
Mailing Address - Street 2:SUITE 425
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1224
Mailing Address - Country:US
Mailing Address - Phone:858-452-1361
Mailing Address - Fax:858-452-8547
Practice Address - Street 1:9850 GENESEE AVE
Practice Address - Street 2:SUITE 425
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1224
Practice Address - Country:US
Practice Address - Phone:858-452-1361
Practice Address - Fax:858-452-8547
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG37047207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA46928Medicare UPIN
CAG37047Medicare ID - Type Unspecified