Provider Demographics
NPI:1881836013
Name:RUDOLPH, DAVID SAMUEL (DO)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:SAMUEL
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 COLLIER RD NW
Mailing Address - Street 2:SUITE 4075
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-1796
Mailing Address - Country:US
Mailing Address - Phone:404-355-3200
Mailing Address - Fax:
Practice Address - Street 1:354 NEWNAN CROSSING BYP
Practice Address - Street 2:SUITE 205
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2323
Practice Address - Country:US
Practice Address - Phone:678-326-4812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014560207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OS14560OtherPA MEDICAL LICENSE #
PA1922077643OtherMLHC GROUP NPI #
PA440771OtherMLHC MEDICARE AA#
PA824305OtherBS AA#
PA037276OtherMLHC GROUP AA #