Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | MD00041809 | WA |
N | 207QA0401X | Family Doctor - Addiction Medicine | MD00041809 | WA |
NPI | 1871524728 |
---|---|
Provider Name | Gregory D Rudolf |
First Address | Salt Lake City, UT 84125-0608 |
Second Address | Seattle, WA 98122 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/07/2006 |
Last Update Date | 02/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1120542 | (05) | WA |
1871524728 | (05) | WA |
H87939 | (02) |