Provider Demographics
NPI:1548503022
Name:RUDOLPH, JOHN BRADLEY (DO)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BRADLEY
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:415 6TH STREET
Mailing Address - Street 2:ATTN: PHYSICIAN SERVICES
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-2434
Mailing Address - Country:US
Mailing Address - Phone:208-750-7462
Mailing Address - Fax:208-750-7467
Practice Address - Street 1:415 6TH ST STE 3C
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-2431
Practice Address - Country:US
Practice Address - Phone:208-750-7300
Practice Address - Fax:208-746-4899
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2024-12-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WAOP60506022207Q00000X
IDO-0990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine