Provider Demographics
NPI:1629200308
Name:RUDOLPH, MATTHEW BRIAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRIAN
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1123 S PALESTINE ST
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3646
Mailing Address - Country:US
Mailing Address - Phone:903-675-9526
Mailing Address - Fax:903-677-1815
Practice Address - Street 1:1123 S PALESTINE ST
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3646
Practice Address - Country:US
Practice Address - Phone:190-367-5952
Practice Address - Fax:903-675-9526
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8727207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty