Provider Demographics
NPI:1700861382
Name:RUDOLPH, THEODOR MAJOR (MD)
Entity type:Individual
Prefix:
First Name:THEODOR
Middle Name:MAJOR
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:TED
Other - Middle Name:MAJOR
Other - Last Name:RUDOLPH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3900 20TH ST
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-2413
Mailing Address - Country:US
Mailing Address - Phone:772-299-4000
Mailing Address - Fax:772-299-4001
Practice Address - Street 1:3900 20TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-2413
Practice Address - Country:US
Practice Address - Phone:772-299-4000
Practice Address - Fax:772-299-4001
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-07
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME79805207NP0225X, 207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261870200Medicaid
FL35625VMedicare ID - Type Unspecified
FLH16206Medicare UPIN