Healthcare Provider Details

I. General information

NPI: 1316085293
Provider Name (Legal Business Name): STEVEN E RUDOLPH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11230 SORRENTO VALLEY RD STE 135
SAN DIEGO CA
92121
US

IV. Provider business mailing address

11230 SORRENTO VALLEY RD STE 135
SAN DIEGO CA
92121
US

V. Phone/Fax

Practice location:
  • Phone: 858-450-6650
  • Fax: 858-450-6651
Mailing address:
  • Phone: 858-450-6650
  • Fax: 858-450-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A6389
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number20A6389
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2046389
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: