Healthcare Provider Details

I. General information

NPI: 1598442766
Provider Name (Legal Business Name): JUAN RUDDY FONDEUR ACOSTA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JUAN RUDDY FONDEUR SONI MD

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date: 02/02/2024
Reactivation Date: 06/18/2024

III. Provider practice location address

1650 GRAND CONCOURSE BRONX-LEBANON HOSPITAL CENTER,
BRONX NY
10457
US

IV. Provider business mailing address

1 COLUMBUS PL APT S12B
NEW YORK NY
10019-8203
US

V. Phone/Fax

Practice location:
  • Phone: 701-901-8203
  • Fax: 718-901-8704
Mailing address:
  • Phone: 929-633-0990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA13127200
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: