Provider Demographics
NPI:1457775520
Name:DAVID RUDOLPH, MD
Entity Type:Organization
Organization Name:DAVID RUDOLPH, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:907-745-8432
Mailing Address - Street 1:561 S DENALI ST STE C
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-6464
Mailing Address - Country:US
Mailing Address - Phone:907-745-8432
Mailing Address - Fax:
Practice Address - Street 1:561 S DENALI ST STE C
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6464
Practice Address - Country:US
Practice Address - Phone:907-745-8432
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMD2033207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1011028Medicaid
AK1011028Medicaid