Provider Demographics
NPI:1639124779
Name:RUDBERG, AVIDAH H (MD)
Entity type:Individual
Prefix:
First Name:AVIDAH
Middle Name:H
Last Name:RUDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6321 DANIELS PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33912-4710
Mailing Address - Country:US
Mailing Address - Phone:239-416-8101
Mailing Address - Fax:239-402-8601
Practice Address - Street 1:9500 BONITA BEACH RD SE STE 201
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-4683
Practice Address - Country:US
Practice Address - Phone:239-441-2932
Practice Address - Fax:239-441-4045
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2025-08-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLME142399208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL124211000Medicaid
G08521Medicare UPIN
NY23623RA971Medicare PIN