Provider Demographics
NPI:1366762106
Name:PUDER, DAVID JOHANN (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHANN
Last Name:PUDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1790 W PARK AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-3116
Mailing Address - Country:US
Mailing Address - Phone:909-334-2608
Mailing Address - Fax:909-255-9752
Practice Address - Street 1:1790 W PARK AVE STE 200
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-3116
Practice Address - Country:US
Practice Address - Phone:909-334-2608
Practice Address - Fax:909-255-9752
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OHAC2822890-K10-0182084P0800X
CAA1201992084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68795OtherAMERICAN BOARD OF PSYCHIATRY AND NEUROLOGY
CAA120199OtherMEDICAL BOARD OF CALIFORNIA
CAA120199OtherMEDICAL BOARD OF CALIFORNIA