Healthcare Provider Details

I. General information

NPI: 1093701377
Provider Name (Legal Business Name): TATYANA RUDERMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date: 03/24/2006
Reactivation Date: 04/03/2006

III. Provider practice location address

5410 15TH AVE
BROOKLYN NY
11219-4321
US

IV. Provider business mailing address

5410 15TH AVE
BROOKLYN NY
11219-4321
US

V. Phone/Fax

Practice location:
  • Phone: 718-436-0771
  • Fax: 718-436-8118
Mailing address:
  • Phone: 718-436-0771
  • Fax: 718-436-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number218176
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: