Provider Demographics
NPI:1538264908
Name:RUDOLPH, REBECCA EVONNE (MD)
Entity type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:EVONNE
Last Name:RUDOLPH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REBECCA
Other - Middle Name:YVONNE
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4123 NE 107TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-7929
Mailing Address - Country:US
Mailing Address - Phone:206-667-7042
Mailing Address - Fax:
Practice Address - Street 1:1660 S COLUMBIAN WAY
Practice Address - Street 2:S-111-GIMC
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-1532
Practice Address - Country:US
Practice Address - Phone:206-768-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00033168207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8286551Medicaid
WAAB23156Medicare ID - Type Unspecified
WA8286551Medicaid