Provider Demographics
NPI:1851366561
Name:RUDOLF, JONATHAN B (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:B
Last Name:RUDOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 CRISTO REY ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8615
Mailing Address - Country:US
Mailing Address - Phone:505-325-4380
Mailing Address - Fax:
Practice Address - Street 1:801 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-5630
Practice Address - Country:US
Practice Address - Phone:505-325-5011
Practice Address - Fax:505-324-2259
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2004-0021207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97526550Medicaid
NMF74243Medicare UPIN
NM341408903Medicare ID - Type Unspecified