Healthcare Provider Details

I. General information

NPI: 1942461512
Provider Name (Legal Business Name): STACY RUSTICO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY DODT M.D.

II. Dates (important events)

Enumeration Date: 06/17/2008
Last Update Date: 08/09/2024
Certification Date: 08/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34520 BOB WILSON DRIVE NAVAL MEDICAL CENTER SAN DIEGO
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-2098
US

V. Phone/Fax

Practice location:
  • Phone: 619-881-9165
  • Fax: 619-532-9184
Mailing address:
  • Phone: 619-881-9165
  • Fax: 619-532-9184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA111715
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberA111715
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: