Provider Demographics
NPI:1316085293
Name:RUDOLPH, STEVEN E (DO)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:E
Last Name:RUDOLPH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11230 SORRENTO VALLEY RD STE 135
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121
Mailing Address - Country:US
Mailing Address - Phone:858-450-6650
Mailing Address - Fax:858-450-6651
Practice Address - Street 1:11230 SORRENTO VALLEY RD STE 135
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121
Practice Address - Country:US
Practice Address - Phone:858-450-6650
Practice Address - Fax:858-450-6651
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A63892084P0800X, 2084P0802X
CA20463892084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A6389OtherLICENSE
RR3745520OtherDEA
CA20A6389OtherLICENSE