Provider Demographics
NPI:1932693629
Name:RUDOLF, LAWRENCE ANDREW (MD)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:ANDREW
Last Name:RUDOLF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:LARRY
Other - Middle Name:ANDREW
Other - Last Name:RUDOLF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1500 CALVARY CHURCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4125
Mailing Address - Country:US
Mailing Address - Phone:636-933-2900
Mailing Address - Fax:636-933-8017
Practice Address - Street 1:1500 CALVARY CHURCH RD STE B
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-4125
Practice Address - Country:US
Practice Address - Phone:636-933-2900
Practice Address - Fax:636-933-8017
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-18
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020041808207Q00000X
MO2018018701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty