Provider Demographics
NPI:1104182328
Name:RUDOLPH, CARLA (DO)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 OLD US 66
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-7200
Mailing Address - Country:US
Mailing Address - Phone:505-286-2396
Mailing Address - Fax:
Practice Address - Street 1:1851 OLD US 66
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7200
Practice Address - Country:US
Practice Address - Phone:505-286-2396
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-02
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1770-13208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1104182328Medicaid