Healthcare Provider Details

I. General information

NPI: 1083766497
Provider Name (Legal Business Name): RUDDY PEREZ R.N.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 WASHINGTON ST
BOSTON MA
02118-1951
US

IV. Provider business mailing address

7 WINTER ST APT 2
BOSTON MA
02136-2635
US

V. Phone/Fax

Practice location:
  • Phone: 617-425-2040
  • Fax: 617-425-2043
Mailing address:
  • Phone: 617-333-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number252536
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: