Healthcare Provider Details

I. General information

NPI: 1033258363
Provider Name (Legal Business Name): DIANE RUTKOWSKY M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 08/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 N. COUNTRY RD. SUITE 201
MT. SINAI NY
11766
US

IV. Provider business mailing address

45 SHERWOOD DRIVE
SHOREHAM NY
11786
US

V. Phone/Fax

Practice location:
  • Phone: 631-403-4885
  • Fax: 631-425-4670
Mailing address:
  • Phone: 631-403-4885
  • Fax: 631-425-4670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number001371-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number14000007431
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: