Provider Demographics
NPI:1861477085
Name:RUDOLPH, DANIEL GERRIT (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:GERRIT
Last Name:RUDOLPH
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 1:35 GOODWIN DRIVE
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4100
Mailing Address - Country:US
Mailing Address - Phone:636-933-4141
Mailing Address - Fax:636-931-7007
Practice Address - Street 1:35 GOODWIN DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4122
Practice Address - Country:US
Practice Address - Phone:636-933-4141
Practice Address - Fax:636-931-7007
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO105323208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO203936901Medicaid