Provider Demographics
NPI:1376502997
Name:RUDOLPH, LANCE A (MD)
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:A
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 OAK ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4725
Mailing Address - Country:US
Mailing Address - Phone:505-855-5525
Mailing Address - Fax:505-884-4006
Practice Address - Street 1:300 OAK ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4725
Practice Address - Country:US
Practice Address - Phone:505-855-5525
Practice Address - Fax:505-884-4006
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83-104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000Z5691Medicaid
NMNM004414OtherBCBS NM/HMO NM
NM000-16667Medicaid
NM000-16667Medicaid