MEDICARE: DR. CLIFTON RUDOLPH LAKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	ACN1119	FL
2	283Q00000X	Psychiatric Hospital	P60621	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063698330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLIFTON RUDOLPH LAKE MD

Provider Business Mailing Address
First Line	:	46 BROOK RD
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2416
Country	:	US
Telephone Number	:	516-508-0128
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 BROOK RD
Second Line	:
City	:	VALLEY STREAM
State	:	NY
Zip	:	11581-2416
Country	:	US
Telephone Number	:	516-508-0128
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/16/2008
Last Update Date	:	05/20/2020

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