Healthcare Provider Details

I. General information

NPI: 1114924354
Provider Name (Legal Business Name): RANDALL S. PRUST MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2005
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4747 E CAMP LOWELL DR
TUCSON AZ
85712-1256
US

IV. Provider business mailing address

4747 E CAMP LOWELL DR
TUCSON AZ
85712-1256
US

V. Phone/Fax

Practice location:
  • Phone: 520-731-5540
  • Fax: 520-731-5541
Mailing address:
  • Phone: 520-322-2560
  • Fax: 520-731-5541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDALL S. PRUST
Title or Position: PRESIDENT
Credential: M.D.
Phone: 520-731-4450