Provider Demographics
NPI:1457663809
Name:RUDOLPH, CHASE AARON (OD)
Entity Type:Individual
Prefix:DR
First Name:CHASE
Middle Name:AARON
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3121 S PARK AVE.
Mailing Address - Street 2:
Mailing Address - City:HERRIN
Mailing Address - State:IL
Mailing Address - Zip Code:62948
Mailing Address - Country:US
Mailing Address - Phone:618-942-5465
Mailing Address - Fax:618-942-7042
Practice Address - Street 1:3121 S PARK AVE
Practice Address - Street 2:
Practice Address - City:HERRIN
Practice Address - State:IL
Practice Address - Zip Code:62948-3785
Practice Address - Country:US
Practice Address - Phone:618-942-5465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2015-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046010332152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010332Medicaid