Provider Demographics
NPI:1023052446
Name:RUDOLPH, JASON W (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:W
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:PO BOX 783311
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-3311
Mailing Address - Country:US
Mailing Address - Phone:484-884-4500
Mailing Address - Fax:484-884-0699
Practice Address - Street 1:2775 SCHOENERSVILLE RD
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18017-7307
Practice Address - Country:US
Practice Address - Phone:610-861-8080
Practice Address - Fax:610-997-5762
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067886L174400000X, 207X00000X, 207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery
No174400000XOther Service ProvidersSpecialist
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017598980001Medicaid
S68239Medicare UPIN
PA0017598980001Medicaid