Basic Information
| Provider Information | |||||||||
| NPI: | 1528145752 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUDIKOFF | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 SELWYN AVE | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189601234 | ||||||||
| FaxNumber: | 7189602055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 SELWYN AVE | ||||||||
| Address2: | 10TH FLOOR | ||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189601234 | ||||||||
| FaxNumber: | 7189602055 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 121270 | NY | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 00698577 | 05 | NY | MEDICAID |