Provider Demographics
NPI:1083846034
Name:RUDOLPH, CAROL S (MD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:S
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4949 S CONGRESS AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-4731
Mailing Address - Country:US
Mailing Address - Phone:561-433-8500
Mailing Address - Fax:561-641-6821
Practice Address - Street 1:4949 S CONGRESS AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-4731
Practice Address - Country:US
Practice Address - Phone:561-433-8500
Practice Address - Fax:561-641-6821
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 50492207W00000X, 208VP0014X
FL50492207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD20801Medicare UPIN