1588941819 NPI number — DR. MARTIN RUDOLPH DPM PC

Table of content: (NPI 1588941819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588941819 NPI number — DR. MARTIN RUDOLPH DPM PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MARTIN RUDOLPH DPM PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588941819
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
391 LAUREL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCKVILLE CENTRE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11570-1416
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-594-0608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
551 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 21A
Provider Business Practice Location Address City Name:
CEDARHURST
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11516-2192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
516-569-3009
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
RUDOLPH
Authorized Official First Name:
MARTIN
Authorized Official Middle Name:
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
516-594-0608

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  025119 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00414475 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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