Healthcare Provider Details

I. General information

NPI: 1407917875
Provider Name (Legal Business Name): WILLIAM GARTH RUDOLPH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 FIRST COLONIAL RD SUITE 200
VIRGINIA BEACH VA
23454-2406
US

IV. Provider business mailing address

1080 FIRST COLONIAL RD SUITE 200
VIRGINIA BEACH VA
23454-2406
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-6070
  • Fax: 757-395-6381
Mailing address:
  • Phone: 757-395-6070
  • Fax: 757-395-6381

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0101241931
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number0101241931
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: