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NPI Code Detail

MEDICARE: LISA ALEXANDRA RUDOLPH

MEDICARE: LISA ALEXANDRA RUDOLPH
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
1174400000XSpecialistNY

General Provider Information

NPI Number : 1750226585
Entity Type Code : Individual
Provider Name (Legal Business Name) : LISA ALEXANDRA RUDOLPH
Provider Business Mailing Address
First Line : PO BOX 12
Second Line :
City : MIDDLE ISLAND
State : NY
Zip : 11953-0012
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 35 LONGWOOD RD
Second Line :
City : MIDDLE ISLAND
State : NY
Zip : 11953-2045
Country : US
Telephone Number : 631-924-0008
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/20/2026
Last Update Date : 04/20/2026

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Directions to “ LISA ALEXANDRA RUDOLPH ” Practice Location

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