Healthcare Provider Details

I. General information

NPI: 1346376308
Provider Name (Legal Business Name): GEORGE STABEN RUST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 01/14/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 ROBERTS AVE
TALLAHASSEE FL
32310-5007
US

IV. Provider business mailing address

1115 W CALL ST FSU-COM, DEPT OF BSSM
TALLAHASSEE FL
32304-3556
US

V. Phone/Fax

Practice location:
  • Phone: 850-644-1543
  • Fax: 855-230-7421
Mailing address:
  • Phone: 850-644-1543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License NumberME46256
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME46256
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: