Provider Demographics
NPI:1619034246
Name:RUDOLPH, IRA DOUGLAS (PHD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:DOUGLAS
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 NEWBURY STREET SUITE 404
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116
Mailing Address - Country:US
Mailing Address - Phone:617-536-2052
Mailing Address - Fax:
Practice Address - Street 1:45 NEWBURY STREET SUITE 404
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116
Practice Address - Country:US
Practice Address - Phone:617-536-2052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4466103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW04332Medicare ID - Type Unspecified