Provider Demographics
NPI:1386636348
Name:RUDOLPH, CHARLES N (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:N
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 1:4510 EXECUTIVE DRIVE
Mailing Address - Street 2:SUITE 125
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121
Mailing Address - Country:US
Mailing Address - Phone:858-678-0455
Mailing Address - Fax:858-678-0391
Practice Address - Street 1:4150 REGENTS PARK ROW STE 321
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9124
Practice Address - Country:US
Practice Address - Phone:858-678-0455
Practice Address - Fax:858-678-0391
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG60659207R00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG60659AMedicare ID - Type Unspecified
E70158Medicare UPIN
CA4436150001Medicare NSC
CAW15482Medicare PIN
CAE70158Medicare UPIN