Healthcare Provider Details

I. General information

NPI: 1568129286
Provider Name (Legal Business Name): DIANNE RUST CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2021
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 BLOSSOM HILL RD APT A14
LOS GATOS CA
95032-4537
US

IV. Provider business mailing address

517 BLOSSOM HILL RD APT A14
LOS GATOS CA
95032-4537
US

V. Phone/Fax

Practice location:
  • Phone: 408-887-7107
  • Fax:
Mailing address:
  • Phone: 408-887-7107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number7990
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: