Healthcare Provider Details

I. General information

NPI: 1487440335
Provider Name (Legal Business Name): GREGORY RUDDY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

IV. Provider business mailing address

2817 ROCK MERRITT AVE
FORT BRAGG NC
28310-0001
US

V. Phone/Fax

Practice location:
  • Phone: 910-907-8707
  • Fax:
Mailing address:
  • Phone: 910-907-8707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number1589436519
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: