Provider Demographics
NPI:1558874487
Name:RUDOLPH, DANIEL ROBERT (DPT)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROBERT
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26571 NORMANDALE DR APT 17C
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-6768
Mailing Address - Country:US
Mailing Address - Phone:732-232-7180
Mailing Address - Fax:
Practice Address - Street 1:32261 CAMINO CAPISTRANO STE D101
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3747
Practice Address - Country:US
Practice Address - Phone:949-429-2155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-14
Last Update Date:2017-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294068225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist