Basic Information
Provider Information | |||||||||
NPI: | 1700861382 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | RUDOLPH | ||||||||
FirstName: | THEODOR | ||||||||
MiddleName: | MAJOR | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUDOLPH | ||||||||
OtherFirstName: | TED | ||||||||
OtherMiddleName: | MAJOR | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 3900 20TH ST | ||||||||
Address2: |   | ||||||||
City: | VERO BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329602413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722994000 | ||||||||
FaxNumber: | 7722994001 | ||||||||
Practice Location | |||||||||
Address1: | 3900 20TH ST | ||||||||
Address2: |   | ||||||||
City: | VERO BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 329602413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7722994000 | ||||||||
FaxNumber: | 7722994001 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2005 | ||||||||
LastUpdateDate: | 09/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | ME79805 | FL | N |   | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology | 207ND0101X | ME79805 | FL | N |   | Allopathic & Osteopathic Physicians | Dermatology | MOHS-Micrographic Surgery | 207NS0135X | ME79805 | FL | N |   | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207N00000X | ME79805 | FL | Y |   | Allopathic & Osteopathic Physicians | Dermatology |   |
ID Information
ID | Type | State | Issuer | Description | 261870200 | 05 | FL |   | MEDICAID |