Healthcare Provider Details

I. General information

NPI: 1083846034
Provider Name (Legal Business Name): CAROL S. RUDOLPH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 08/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4949 S CONGRESS AVE STE B
LAKE WORTH FL
33461-4731
US

IV. Provider business mailing address

4949 S CONGRESS AVE STE B
LAKE WORTH FL
33461-4731
US

V. Phone/Fax

Practice location:
  • Phone: 561-433-8500
  • Fax: 561-641-6821
Mailing address:
  • Phone: 561-433-8500
  • Fax: 561-641-6821

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME 50492
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number50492
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberME 50492
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: