Provider Demographics
NPI:1629200308
Name:RUDOLPH, MATTHEW BRIAN (DO)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRIAN
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 1:4002 S LOOP 256 STE B
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-8405
Mailing Address - Country:US
Mailing Address - Phone:903-731-5478
Mailing Address - Fax:903-731-5042
Practice Address - Street 1:4002 S LOOP 256 STE B
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-8405
Practice Address - Country:US
Practice Address - Phone:903-731-5478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8727207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty