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: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date: 02/02/2024
Reactivation Date: 06/18/2024

III. Provider practice location address

318 KNICKERBOCKER AVE
BROOKLYN NY
11237-3888
US

IV. Provider business mailing address

PO BOX 746087
ATLANTA GA
30374-6087
US

V. Phone/Fax

Practice location:
  • Phone: 718-765-6056
  • Fax: 347-803-1874
Mailing address:
  • Phone: 833-804-1695
  • Fax: 312-929-0373

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number347368
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: