Basic Information
| Provider Information | |||||||||
| NPI: | 1821086992 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RUDOLPH | ||||||||
| FirstName: | MAJ-STINA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4900 S MONACO ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802373486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033603260 | ||||||||
| FaxNumber: | 3033603388 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 POTOMAC ST | ||||||||
| Address2: | 3RD FLOOR | ||||||||
| City: | AURORA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 800116844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033603260 | ||||||||
| FaxNumber: | 3033603388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 04/06/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 42402 | CO | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 78107733 | 05 | CO | MEDICAID |