Provider Demographics
NPI:1376526749
Name:RUDOLPH, DAVID SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SCOTT
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 1:561 S DENALI
Mailing Address - Street 2:STE C
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645
Mailing Address - Country:US
Mailing Address - Phone:907-745-8432
Mailing Address - Fax:907-746-4489
Practice Address - Street 1:561 S DENALI
Practice Address - Street 2:STE C
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645
Practice Address - Country:US
Practice Address - Phone:907-745-8432
Practice Address - Fax:907-746-4489
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2007-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK2066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD2033Medicaid
AK00000HTCQMedicare ID - Type Unspecified
AKMD2033Medicaid
AKK0000BHTCQMedicare PIN