Provider Demographics
NPI:1811216948
Name:RUDOLPH, BRYAN (MD, MPH)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 HOMESTEAD RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-1109
Mailing Address - Country:US
Mailing Address - Phone:202-465-5307
Mailing Address - Fax:
Practice Address - Street 1:3411 WAYNE AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2403
Practice Address - Country:US
Practice Address - Phone:718-741-2332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257025-1208000000X
NY2570252080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03363848Medicaid