Healthcare Provider Details

I. General information

NPI: 1316145832
Provider Name (Legal Business Name): RUSLY HARSONO MD, FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 06/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

1804 EMBARCADERO RD STE. #100, MC 5548
PALO ALTO CA
94303-3341
US

V. Phone/Fax

Practice location:
  • Phone: 650-497-8000
  • Fax:
Mailing address:
  • Phone: 650-723-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number43740
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number002881
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA92797
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD426037
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number002881
License Number StateNY
# 6
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA92797
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberMD426037
License Number StatePA
# 8
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number43740
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: