Healthcare Provider Details

I. General information

NPI: 1154480895
Provider Name (Legal Business Name): RANDI M. RUSH DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 09/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23388 MULHOLLAND DR.
WOODLAND HILLS CA
91364
US

IV. Provider business mailing address

23388 MULHOLLAND DR.
WOODLAND HILLS CA
91364
US

V. Phone/Fax

Practice location:
  • Phone: 818-876-1888
  • Fax:
Mailing address:
  • Phone: 818-876-1888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number20A8836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: