Provider Demographics
NPI:1023128287
Name:SANTOSO, RUDY A (MD)
Entity type:Individual
Prefix:DR
First Name:RUDY
Middle Name:A
Last Name:SANTOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1019 LENOIR RHYNE BLVD SE
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28602-4331
Mailing Address - Country:US
Mailing Address - Phone:828-324-4143
Mailing Address - Fax:828-324-0225
Practice Address - Street 1:327 1ST AVE NW
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-6122
Practice Address - Country:US
Practice Address - Phone:828-695-5900
Practice Address - Fax:828-695-4256
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC261482084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC74543OtherBCBS
NC183254OtherMEDCOST
NC259250000OtherMAGELLAN
NC7974543Medicaid
NC7974543Medicaid
NC183254OtherMEDCOST