Provider Demographics
NPI:1275526501
Name:ANDERSON, RUDOLPH CLINTON JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:RUDOLPH
Middle Name:CLINTON
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N BEAUREGARD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22311-1732
Mailing Address - Country:US
Mailing Address - Phone:703-940-3810
Mailing Address - Fax:703-940-3811
Practice Address - Street 1:1600 N BEAUREGARD ST STE 300
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22311-1732
Practice Address - Country:US
Practice Address - Phone:703-940-3810
Practice Address - Fax:703-940-3811
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103001041213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9304240Medicaid
U71771Medicare UPIN