Healthcare Provider Details

I. General information

NPI: 1366762106
Provider Name (Legal Business Name): DAVID JOHANN PUDER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 03/07/2023
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1790 W PARK AVE STE 200
REDLANDS CA
92373-3116
US

IV. Provider business mailing address

1790 W PARK AVE STE 200
REDLANDS CA
92373-3116
US

V. Phone/Fax

Practice location:
  • Phone: 909-334-2608
  • Fax: 909-255-9752
Mailing address:
  • Phone: 909-334-2608
  • Fax: 909-255-9752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAC2822890-K10-018
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA120199
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: