Healthcare Provider Details

I. General information

NPI: 1134530033
Provider Name (Legal Business Name): LAUREN RUDOLPH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 E 13TH ST STE 105
LOVELAND CO
80537-5134
US

IV. Provider business mailing address

4832 MARIANA HILLS CIR
LOVELAND CO
80537-7930
US

V. Phone/Fax

Practice location:
  • Phone: 319-384-7765
  • Fax:
Mailing address:
  • Phone: 720-937-7954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberR-11267
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberDR.0062433
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: